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Washington State Institute for Public Policy
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Cesarean section reduction programs: Continuous support (Medicaid population)

Healthcare: Maternal and Infant Health
Benefit-cost methods last updated December 2024.  Literature review updated November 2015.
These hospital-based interventions measure the influence of continuous emotional and physical support for women in labor in reducing medical interventions, specifically cesarean sections. The scope of the interventions varies, from solely intrapartum support to pre-natal education and post-partum care and lactation support. Similarly, the nature of the practitioner also varies, including nurses with additional training, doulas who are not included in hospital staff, or friends or family of the laboring mother who have received additional training. Only studies that use a control group—women with a support person (e.g. partner or family member)—are included here to increase generalizability to Washington State’s population.

The benefits presented in the benefit-cost analysis are specific to the Medicaid population.
 
ALL
BENEFIT-COST
META-ANALYSIS
CITATIONS
For an overview of WSIPP's Benefit-Cost Model, please see this guide. The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2023).  The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $96 Benefits minus costs ($334)
Participants $0 Benefit to cost ratio ($0.05)
Others $0 Chance the program will produce
Indirect ($111) benefits greater than the costs 1%
Total benefits ($15)
Net program cost ($319)
Benefits minus cost ($334)

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the program impacts measured in the research literature (for example, impacts on crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases. See Estimating Program Effects Using Effect Sizes for additional information on how we estimate effect sizes.

The effect size may be adjusted from the unadjusted effect size estimated in the meta-analysis. Historically, WSIPP adjusted effect sizes to some programs based on the methodological characteristics of the study. For programs reviewed in 2024 or later, we do not make additional adjustments, and we use the unadjusted effect size whenever we run a benefit-cost analysis.

Research shows the magnitude of effects may change over time. For those effect sizes, we estimate outcome-based adjustments, which we apply between the first time ES is estimated and the second time ES is estimated. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Treatment age No. of effect sizes Treatment N Effect sizes (ES) and standard errors (SE) used in the benefit-cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Cesarean sections
Surgical delivery of an infant.
 26 5 4327 -0.093 0.090 26 0.000 0.000 27 -0.093 0.304
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Affected outcome: Resulting benefits:1 Benefits accrue to:
Taxpayers Participants Others2 Indirect3 Total
Cesarean sections Health care associated with Cesarean sections $96 $0 $0 $48 $144
Program cost Adjustment for deadweight cost of program $0 $0 $0 ($159) ($159)
Totals $96 $0 $0 ($111) ($15)
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Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $257 2014 Present value of net program costs (in 2023 dollars) ($319)
Comparison costs $0 2014 Cost range (+ or -) 10%
Per-participant cost is the reimbursement rate from Minnesota Medicaid for the cost of a doula for a labor and delivery session. This does not include reimbursement for additional prenatal or postnatal education and/or counseling.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Benefits Minus Costs
Benefits by Perspective
Taxpayer Benefits by Source of Value
Benefits Minus Costs Over Time (Cumulative Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in discounted dollars. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

Citations Used in the Meta-Analysis

Campbell, D.A., Lake, M.F., Falk, M., & Backstrand, J.R. (2006). A randomized control trial of continuous support in labor by a lay doula. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 35(4), 456-464.

Gagnon, A.J., Waghorn, K., & Covell, C. (1997). A randomized trial of one-to-one nurse support of women in labor. Birth, 24(2), 71-77.

Gordon, N.P., Walton, D., McAdam, E., Derman, J., Gallitero, G., & Garrett, L. (1999). Effects of providing hospital-based doulas in health maintenance organization hospitals. Obstetrics & Gynecology, 93(3), 422–426.

Hodnett, E.D., Lowe, N.K., Hannah, M.E., Willan, A.R., Stevens, B., Weston, J.A., . . . Nursing Supportive Care in Labor Trial Group. (2002). Effectiveness of nurses as providers of birth labor support in North American hospitals: a randomized controlled trial. Jama, 288(11), 1373-1381.

McGrath, S.K., & Kennell, J.H. (2008). A randomized controlled trial of continuous labor support for middle-class couples: Effect on cesarean delivery rates. Birth, 35(2), 92-97.