Doula Care Reduces C-sections, Pre-term Birth & Cuts Birthing Costs by a Net $1,000

AHCCCS Actively Working Toward Incorporating Doula Care as a Covered Service but ADHS Still Hasn’t Developed the Certification Regulations

Those of you that attended the health equity conference last week were treated to a terrific late morning panel discussing a range of reproductive health topics including: 1) maternal mortality interventions; 2) local health policies that promote access to care for birthing people and infants; 3) overcoming barriers to care for birthing people and infants in Arizona, and 4) opportunities for cross-sector collaborations.

Several of the speakers (DeShawn Taylor, MDJennifer Piatt, JDZaida Dedolph Piecoro,Sara Salek, MD, and Jacqueline Badine) mentioned the role that Doula care can play in improving birth outcomes (especially Ms. Badine). Their discussions inspired me to take a deeper dive into Doula care this week, so here goes.

A doula is a trained professional who provides physical, emotional, and informational support to a woman throughout her pregnancy, childbirth, and postpartum period. Doulas act as a facilitator between the laboring women and her physician by ensuring that the mother gets the required information to make informed decisions.

Several studies have shown that moms who have doula services during their pregnancy and delivery have fewer cesarean sections and epidurals, reduced premature births, higher rates and a longer duration of breastfeeding, while substantially reducing birthing costs

In March 2014, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal medicine issued a consensus statement which explicitly stated that published data has indicated better labor and delivery outcomes when continuous support personnel such as doulas are used. In addition to improving birth outcomes, doula care has a high return on investment.

Doula care reduces healthcare costs by lowering the rate of pre-term and C-section deliveries to the tune of about $1,000 per doula-supported birth

Fortunately, the word that doula care improves health outcomes while reducing healthcare costs has struck a chord- and Arizona policy is slowly moving toward integrating doula care into the network, including AHCCCS coverage.

The strategy for building doula care into the network is much like the model we used for Community Health Workers…  build a professional certification process, followed by amending AHCCCS’ waiver with CMS to provide for reimbursement for the services.

Back in 2021, the legislature passed, and the governor signed a new law [ARS 36-766.01-09charging the ADHS with developing rules to certify doulas including a scope of practice, qualifications, standards for education and training programs and compliance criteria. The law gave ADHS ‘exempt’ rulemaking authority- which is essentially the diamond lane for writing rules (there’s no excuse for slow-walking them).

While ADHS hasn’t made any tangible progress on that rulemaking yet, they’ve at least published a ‘Notice of Public Information‘ with the Secretary of State.

The slow pace of the rulemaking shows that finishing the rule isn’t a priority for the current ADHS director, but it might be a higher priority for whoever is appointed to that post a few months from now.

At the Health Equity Conference last week, AHCCCS’ Chief Medical Officer (Dr. Sara Salek) mentioned that the agency is in the process of preparing an amendment to their state plan to incorporate doula care as a covered service. Hopefully the next ADHS director will get on the stick and finalize the doula certification rules in time for certification to be available by the time AHCCCS is able to complete their paperwork with CMS. 

Also See:  Doula Coverage to Help Minimize Arizona’s Birth Woes

Message from AzPHA Member Dr. Leonard Kirschner: Nine Big Lies & One Big Truth

Ken Burns gripping documentary, “The U.S. and the Holocaust” brought back memories of my own family. My four grandparents immigrated from eastern Europe in the 1890’s and settled in New York. My parents were born in New York, met, married and had two children in the city. My father and his sister were orphaned and raised by cousins. My father got his college degree from City College, his Master’s in Business from NYU, and became the Chief Operating Officer of an international textile corporation with headquarters in New York.

My aunt moved to Paris in the 1920’s to study at the Sorbonne. When the war started, she joined the OSS (the precursor to the CIA). She served in North Africa and Europe. A true immigrant story. At the end of the war, my aunt returned to Europe to search for the cousins she had met in her years living in Paris. They had all perished in the Holocaust. My own history makes me reflect on big lies that have had horrific consequences.

The Big Lie #1. When Adolph Hitler rose to power in 1933, he propagated the big lie that the Jews of Germany had caused the country to lose World War 1. He added to that lie by saying the Jewish population was the cause of all the problems the country faced in the Great Depression. Joseph Goebbels, his Minister of Propaganda, said it well: “A lie once told remains a lie, but a lie told 1000 times becomes the truth.” My dear friend Sue was born in Stuttgart, Germany, in 1937, into a family that had lived in the country for centuries. Her father served in the German Army in World War 1 but that did not matter because he was a Jew. They escaped to the United States in 1938. I met Sue when we were in high school. Those big lies led to the death of millions of innocent people.

The Big Lie #2. For hundreds of years witchcraft was believed to exist. There are estimates that tens of thousands of people (mostly women) were convicted of witchcraft and hung, drowned or burned at the stake. The American colonies were not immune to this big lie with the most infamous being the Salem witch trials of 1692-1693 in which 19 individuals were executed. This event has been described as a case of mass hysteria. In the 1950’s, the Massachusetts Legislature passed legislation exonerating the people who had been executed.

The Big Lie #3. Joseph McCarthy was a United States Senator from Wisconsin, serving from 1947 to 1957. He propagated the big lie that the United States was the target of widespread communist subversion. He claimed to have lists of communists in the State Department, the administration of President Truman, the U.S. Army and other government agencies as well as in Hollywood. There were no lists. Eventually Senator Margaret Chase Smith called him out and the Senate censured McCarthy. Today the term, “McCarthyism” stands for a demagogue who makes reckless and unsubstantiated accusations.

The Big Lie #4. “Separate but Equal” was a legal doctrine employed in the years after the Civil War. It included segregation in housing, education, health care, transportation and many other services. The fact is that these services were separate but definitely not equal. The Supreme Court decision in Brown v. Board of Education in 1954 started the dismantling of this noxious practice. The passage of the Civil Rights Act of 1964 was historic. In 1963, I was a newly commissioned USAF Captain stationed at Gunter AFB in Mongomery, Alabama. I was living in a motel in the city when I heard the screech of tires. I went out in the street to find a man who had been hit by a hit and run driver. I gave first aid and called for an ambulance. When the driver arrived, he looked at the injured Africa-American and said we had called the wrong ambulance. We needed to call the “Black Ambulance.”

The Big Lie #5. American Indian boarding schools were established in the United States to “civilize” Native American children. One of the largest schools was in Phoenix, and we still drive on Indian School Road.  The schools were usually harsh as the children were forcibly removed from their families, had their hair cut and were not allowed to speak their native language. Many of the children died, and we are still finding evidence of unmarked graves. Eventually, through court action and legislative victories, the system was shut down.

The Big Lie #6. Following the Japanese attack on Pearl Harbor, President Roosevelt issued Executive Order 9066, that led to the incarceration of some 120,000 people of Japanese ancestry in concentration camps in the western part of the country. That included camps in Arizona. Some two thirds of those incarcerated were United States citizens. The big lie was that they were a threat to the country. That was false. Many volunteered to serve in the military and their units were among the highest decorated combat units in the war. In 1988, President Reagan signed the “Civil Liberties Act” which apologized for the incarceration. My friend Judy was born in Los Angeles in 1938, to Japanese parents. In 1942, she and her entire family were deported to the Poston War Relocation Center on the Colorado River Indian Reservation. At its height, the camp had 17,000 inhabitants and was the third largest city in Arizona. When Judy and family were released in 1945, they returned to Los Angeles but had lost their home and business.

The Big Lie #7. In 1964, the United States and North Vietnam were engaged in a limited confrontation in Southeast Asia. On August 4, 1964, the USS Maddox, an American destroyer, was patrolling in the Gulf of Tonkin between China and North Vietnam. The commander of the Maddox reported that the ship was being attacked by North Vietnamese boats. Later evidence proved that there were no hostile ships in the area. The outcome of this error was the passage of the “Gulf of Tonkin Resolution.” That gave President Johnson the authority to deploy US troops to South Vietnam and commencement of open warfare against North Vietnam. Marines were deployed to DaNang in early 1965, and I arrived there on Labor Day of that year.

The Big Lie #8. Immigration has been a contentious political issue for centuries and remains so today. The term was coined in the 17th century referring to non-warlike population movement. It has been a constant in our country since the landing of the passengers on the Mayflower. They were immigrants fleeing religious intolerance. We, however, have spent time and resources limiting new immigrants. In 1882, Congress passed the first of many immigration laws; “The Chinese Exclusion Act.” In the 1920’s, Congress passed several laws that put quotas on immigration from certain countries. Ken Burns chronicles how those quotas kept scores of people from escaping Nazi Germany death camps. The last comprehensive immigration law was signed by Ronald Regan in 1986. There are any number of big lies concerning immigrants. They won’t assimilate. FALSE! They don’t pay taxes. FALSE!  They are here to get government benefits and won’t work. FALSE!  Today we have a border wall, DACA immigrants, transport to northern cities and other political issues. It is time for Congress to perform its function and act.    

The Big Lie #9. November will be the third anniversary of the start of the Covid pandemic in Wuhan, China. Since then, the disease has ravaged the world with over one million deaths in the United States. One of the great scientific efforts has been the development of vaccines that are safe and effective. That has also led to an avalanche of big lies concerning the vaccines. Let me mention a few. When you get the shot, you will have a microchip injected into your arm, FALSE! The vaccine is made with fetal tissue. FALSE! The shot will alter your DNA. FALSE! The vaccine will make you unable to have children. FALSE! And more big lies.

The Big Truth #1. Joseph Robinette Biden Jr. won the 2020 presidential election.

An Evidence Review: Does Outlawing Abortion Care Harm Public Health?

In a Word, Yes. Here’s How

Laws regulating abortion care in Arizona are very close to fully settled now that Pima County Superior Court Judge Kellie Johnson the lifted the injunction in the Nelson v. PP case. In her decision she dismissed the relevance of the new law limiting abortions to those at less than 15 weeks of gestation because the state legislature included in the session law that the 15-week gestation age limitation does not “… repeal by implication or otherwise Section 13-3603 or any other applicable state law regulating or restricting abortion.”

Women’s Reproductive Rights in Arizona: 1864–2022

Planned Parenthood of Arizona has appealed but given the makeup of the AZ Appellate & Supreme Courts, there is little chance of being overturned. Abortion care will be illegal in Arizona through at least December of 2024, when a voter initiative may change the landscape, repealing ARS 13-3603 and substituting it with alternative regulations.

Abortion Care Now Largely Illegal in Arizona

Pregnant persons of means will be able to travel to clinics in Las Vegas and Southern California for abortion care…  (see this clinic locator) but many with fewer resources will not be able to… begging the question:

What will the public health impact be from the ending of abortion care in Arizona?

The most comprehensive analysis done to date is the ‘The Turnaway Study’ which is a longitudinal study examining the effects of unwanted pregnancy on women’s lives.

The Turnaway Study: Ten Years, a Thousand Women, and the Consequences of Having or Being Denied an Abortion

The major aim of the study is to describe the mental health, physical health, and socioeconomic consequences of receiving an abortion compared to carrying an unwanted pregnancy to term. Among the study’s top-level findings is that receiving an abortion does not harm the health and wellbeing of women, however, being denied an abortion results in worse financial, health and family outcomes.

The Turnaway Study found serious consequences are more likely to occur when women are denied a wanted abortion including a 400% increased risk of living below the Federal Poverty Level, which causes a cascade of bad health outcomes and intergenerational poverty.

Beyond a 400% increase in the risk of living in poverty, the Study found that women denied an abortion also are:

  • More likely to experience serious complications from the end of pregnancy;
  • More likely to stay tethered to abusive partners;
  • Less likely to have aspirational life plans for the coming year; and
  • More likely to experience poor physical health for years after the pregnancy.

The study also finds that being denied abortion has serious implications for the children born of unwanted pregnancy, as well as for the existing children in the family.

The study also found that many of the common claims about the detrimental effects on women’s health of having an abortion are not supported by evidence. 

For example, women who have an abortion are not more likely than those denied the procedure to have depression, anxiety, or suicidal ideation. Their findings suggest that 95% of women report that having the abortion was the right decision for them over five years after the procedure.

Here are some resources that make the results of the Turnaway Study more digestible:

Issue briefs on the mental health and socioeconomic consequences of having an abortion versus carrying an unwanted pregnancy to term are also available.

More than fifty scientific papers in peer-reviewed journals have used the findings of the Turnaway Study. Here’s a bibliography that provides a complete list of publications. 

For a deep dive into the Turnaway Study including the study’s design, methods, analysis, results, and conclusions visit The Turnaway Study | ANSIRH (Advancing New Standards in Reproductive Health).