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Why Doula Services Should Become an Essential Health Benefit in New York State. Jalisha Henshaw, Amy White, SM Health Services Administration, Lehman College Abstract Doulas are birth workers who assist expecting mothers through pregnancy, birth and postpartum using holistic techniques. Techniques include: prenatal yoga, birth affirmations and induction acupuncture. Doulas are underrated healthcare providers who deserve the same respect as clinical and nonclinical providers. Doulas are well-rounded alternative care providers who focus on mental, emotional, and physical well being of mothers. Also, they know special alternative medical techniques that prevent mothers from maternal mortality among other negative health outcomes. The amount of time and effort doulas perform with expecting mothers are equal or more than the average medical healthcare provider and should be a covered essential health benefit. Step 3: Based on Thomas (2017), the Birth by My Side study, doulas will conduct three prenatal home visits, describing their doula services and screening for signs of depression. Based on the doula’s certification, they will be able to perform holistic techniques on the expecting mothers as needed. Doulas will able to witness the birth and provide assistance and guidance to the mother during labor and birthing process. The comparison group, “ social –providers, ” will visit the mothers twice to evaluate their emotional, mental and physical health before (37 weeks, 3 rd trimester) and after birth ( weeks postpartum). The social-providers and doulas will work closely with primary care providers as form of collaborative care. Outcomes and cost data will be collected via MS Excel. Introduction Literature Review City Council of New York City states they know doulas have a positive effect. “Making doula care accessible to all women in New York City would be a game changer in ensuring individuals have access to the quality care and support they need for a healthy pregnancy and birth” (West-Gray, 2018), Doula services should be an essential health benefit for expecting and postpartum mothers because it decreases maternity mortality rate. Alternative health and medicine have been around for thousands of years to cure diseases and illnesses, and so has midwifery. Western Medicine, including obstetrics/gynecology (OBGYN) has only existed for about a century. In the United States over the last fifty years maternal mortality rates are increasing (CDC, 2018) while midwifery/doula service has not received sufficient attention (. Doula services should be promoted in primary-care clinics, outpatient clinics, hospitals and etc. These services can be expensive but less costly than having hospital and caesarian births (C-section) (Kozhimannil, 2016). Also, this limits women who are low-income who need these services the most. Doula services should be covered by health insurances, such as Medicaid, Empire plan, and Aetna. New York State has the support on Doula/Midwifery work and should take advantage before the maternity mortality rises. Kozhimannil’s 2016 study explains the difference in Medicaid-funded deliveries and those with doula support. Among live births, cesarean sections occurred in 34. 2% of Medicaid-funded deliveries compared to 20. 4% Medicaid-funded deliveries with doula services. As for preterm birth, which is one of the highest healthcare expenditures in the U. S. , 6. 3% occurred in Medicaid-funded deliveries compared to 4. 7% rate among doulasupported deliveries. Figure 1 presents the $58. 4 million saved with Medicaid with doula support and decreased rates of pre-term births and Csections. That is 73. 3% cost savings resulting from doula supported births. This study proposes a randomized case-control of expecting mothers with Medicaid comparing outcomes for a doula services group to social provider control group from second trimester to six weeks postpartum. Table 1. Study consort diagram. 67, 082 expecting mothers in NY 489 Clients (BMS Intervention) 1, 935 Clients (Medicaid and Doula Services) 64, 658 Clients (only 2 visits by social-providers) Age 27 Current treatment New treatment Improved Not Improved Discussion codes 11207, 11208, 11212, 11216, 11221, and 11233, in 2010 -2014. Scale 1. Incremental cost-effectiveness analysis. Amount in $ represents break-even amount of reimbursement for doulas at which cost saving is equal to 0. Based on the BMS study in New York, 489 expecting mothers used doula services provided by BMS (Thomas, 2017). Compared to the other clients in the project area who did not receive doula services, only 33. 5% BMS clients had C-section births, 6. 2% preterm births and 6. 5% low birthweight. The results were based on socially underserved communities in NYC. Chart 1 shows the difference between BMS clients and the rest of the project area clients. An overview of the stratified randomize control trail study proposal for doulas to become an essential health benefit to decrease maternal mortality, Age 25 Chart 1. Data from NYC DOHMH department Vital Statistics: birth outcomes for zip Methods and Materials Step 1: All expecting mother will take validated and standardized assessments and questionnaires (PRAMS, AHAR, NISVS & NSDUH) to evaluate their mental and emotional state. Kozhimannil (2016) estimates 1, 935 expecting mothers will be covered by Medicaid and doulas services, 489 clients will have doulas NY Birth by My Side (BMS), and 65, 147 will have Medicaid and access to a social worker until six-weeks postpartum. Step 2: Expecting mothers who have doulas will be given $1, 000 from Governor Cuomo’s pilot study on doula services. Expenditures exceeding $1, 000 will be evaluated postpartum. A study in Illinois provided the concept for a control comparison group: expecting mothers without doulas will be given home visits by “socialservices providers” twice during their pregnancy and on postpartum visit (Han, 2018). The Illinois study presents the differences between social-providers and doula services with two groups of expecting mothers (Han, 2018). There were two fetal/infant deaths with the social-provider groups and no deaths with the doula service groups. Also, there were 12 preterm births among the social-provider group while there were 10 preterm births in the doula group. Figure 2 explains the study methods which will be somewhat mirrored in this proposal. The study examined how the number of visits between the providers affects the results and birth outcomes. The Social-provider group were found to have lower rates of follow ups during the last weeks of pregnancy in comparison to the doula service clients. In the social-provider group, Six clients declined the follows, 12 delivered preterm babies, and 1 fetal death among the social-provider group. BMS Clients (N=489) Project Area (N=34, 912) Cesarean Section 164 (33. 5%) 12, 894 (36. 9%) Preterm birth (<37 Weeks) 31 (6. 3%) 4319 (12. 4%) Low birthweight (<2500 g) 32 (6. 5%) 3882 (11. 1%) Contact References Jalisha Hanshaw Lehman College Jalisha. [email protected] cuny. edu 1. 2. 3. 4. 5. 6. 7. “Countless scientific trails examining doula care demonstrate remarkably improved physical and psychological outcomes for both mother and baby” (DONA 2018). Research demonstrates that doula services should become an essential health benefit to prevent maternal mortality, decrease rates of Csections, and lower total costs. Low-income and socially disadvantaged women are at risk of suffering poor maternal outcomes from low birth weight babies to postpartum depression or even maternal death. Studies presented here with smaller Ns highlight the differences in the intervention care from doulas and care management teams. Doula services are associated with decreased rates of epidurals, C-sections, postpartum depression, and maternal deaths. These factors contribute to health care expenditures being high. “In addition to support during labor and childbirth, the scope of a doula's work often includes prenatal psychosocial support, education, and health promotion as well as attending to women's personal and cultural expectations for childbirth and the transition to motherhood” (Hardeman 2016). With doula intervention, adverse outcomes and costs could decrease. Doulas are not volunteer workers, they are certified birth workers who should be paid during the time of service. Reimbursement for doulas is nonexistent because their services are not considered an essential service. Conclusion All expecting mothers should have access to doula services regardless of their social, education and professional status. There should be engagement with these communities that have limited access to healthy pregnancies and postpartum services. Mothers should be aware that maternal depression can appear at any point in their pregnancy, and that interventions, such as doula services, will decrease the likelihood of depression occurring and steer women to appropriate services. Finally, doulas presence in the delivery room decreases the rate of C-sections which improve postpartum recovery. Centers for Disease Control (August 7, 2018). Pregnancy Mortality Surveillance System. Retrieved from: https: //www. cdc. gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system. htm. Kozhimannil, Kathy and Hardeman, Rachel. 2016. “Coverage for Doula Services: How State Medicaid Programs Can Address Concerns about Maternity Care Cost and Quality”. Birth Issues in Perinatal Care. Hans, Sydney; Edwards, Renee and Zhang, Yudong. 2018. Randomized Controlled Trial of Doula-Home-Visiting Services: Impact on Maternal and Infant Health. Maternal and Child Health Journal. Mehra, Renee; Cunningham, Shayna; Lewis, Jessica; Thomas, Jordan; Ichovics, Jeannette. 2019. Recommendations for Pilot Expandion of Medicaid Coverage for doulas in New York State. American Journal of Public Health. Thomas, Mary-Powel; Ammann, Gaberiela; Braizer, Ellen. 2017. Doula Services within a Health Start Program: Increasing Access for an Underserved Population. CUNY School of Public Health, Publications and Research. Hardeman, Rachel and Kozhimannil. 2016. “Motivations for Entering the Doula Profession: Perspectives From women of Color. Journal of Midwifery & Women’s Health. What is a doula? . www. dona. org. Dona International. 2019.