Assessing the Impact of the Initiation of the Doula Medicaid Reimbursement Policy on Cesarean Rates

Background: Cesarean sections are one of the main maternal morbidities of concern in the US. An alarming trend is that maternal mortality rates have increased from an estimated 20.1 per 100,000 births in 2019 to 23.8 per 100,000 births in 2020 (Njoku et al., 2023). African American women experience the highest maternal mortality rates of all racial groups (Njoku et al., 2023). Reducing cesarean section (C-section) rates is critical, as C-sections are associated with increased postpartum health risks such as prolonged recovery, postpartum depression (PPD), hemorrhaging, impaired milk production, and complications with future vaginal deliveries (Njoku et al., 2023; Declercq et al., 2014; Guglielminotti et al., 2022). This quantitative study focuses on the impact of health insurance coverage on the mode of delivery, to assess the impact of the initiation of the doula Medicaid Reimbursement Policy.

Method: I used the birth data sets from the Center for Disease Control Wonder Natality data from 2018-2024. As of 2024, a total of 13 states have officially started Medicaid reimbursement of doula services’ thus, 38 states constituted the control group (of 51 states in total). The percentage of births that were cesarean sections out of total births for the county of each state was the dependent variable and the presence of the Medicaid Doula Reimbursement Policy was the independent variable and determined the treated states from the untreated states (control). Medicaid reimbursement started at different years across the states with the policy, so we needed to account for the difference in time point effects of the policy as this will impact our ability to measure effect post and pre “treatment” (Huntingon-Klein, 2021).

Data Analysis: I used a difference in differences model with the Calloway & Sant’Anna DID to examine multiple states with varying start dates of Medicaid reimbursement, comparing states with the policy from those without the policy. A difference of those differences over the years 2018-2024 accounted for the staggered effect (Huntingon-Klein, 2021).

Results: Findings showed a 2.1% point decrease in the rate of cesarean sections for those receiving Medicaid but it was not statistically significant (p value = 0.311). When accounting for staggered adoption, there was no observed difference 3 years before policy. For the year the policy starts, there is an immediate effect .36 % point decrease c-sections rates out of total births by state that was not statistically significant (p value = 0.59). Finally, 3 years after policy, average treated states saw a statistically significant 3.45%-point decrease (p<.001).

Discussion: The study was limited by a lack of access to 2025 data and data restrictions regarding number of covariates. Access to doulas continues to expand nationally, but there are challenges such as inclusion in healthcare settings, coverage by private health insurance, and doula incorporation at all hospitals. The profession of doulas has shown to engage in inclusive and democratic practices to make the environment of maternal health for vulnerable populations more equitable and being able to access data on their impact is at the core of social justice.