Introduction: Multiple studies have demonstrated the benefits of receiving doula care during labor and delivery, although analyses elucidating the cost-effectiveness of a doula's presence are limited. We sought to study the cost-effectiveness and outcomes associated with doula care during the first delivery on the first and second deliveries.

Methods: A cost-effectiveness model using TreeAge software was designed to compare outcomes in women with a trained doula vs. no doula. We used a theoretical cohort of 1.8 million women, the approximate number of nulliparous term births in the US annually. The cost of a doula in Oregon is between $600-2,000 with an average of $1,000 for a healthy woman. Outcomes included mode of delivery, maternal death, uterine rupture and hysterectomy, in addition to cost and quality-adjusted life years (QALY). Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY. Sensitivity analyses were used to investigate the robustness of the results.

Results: In our theoretical cohort, we found that the presence of a trained doula during the first delivery resulted in 219,530 fewer cesarean deliveries, 51 fewer maternal deaths, 382 fewer uterine ruptures, and 100 fewer hysterectomies, saving $91 million with 7,227 increased QALYs for the first and subsequent delivery. Sensitivity analyses demonstrated cost-effectiveness up to $1,452 per doula.

Conclusion/Implications: The presence of a trained doula during a woman's first delivery leads to improved outcomes, decreased costs and increased QALYs during her first and second delivery. This model argues for increased reimbursement for doula care, thereby promoting improved health for our patients.