Leveling the start: cost-effectiveness of community-based doula care among Medicaid births∗

Alabama consistently ranks among the worst states for infant health outcomes, facing a severe crisis marked by high preterm birth rates, and significant racial disparities. Doula support during pregnancy, childbirth, and postpartum is associated with improved birth experiences and outcomes, but access is limited for people with low income. As more states add Medicaid reimbursement for doula care, local evidence can inform benefit design and equity-focused maternal health strategies. We evaluate associations between doula services and maternal and infant health outcomes among Medicaid singleton births in Alabama. Alabama birth certificate data is used to sample Medicaid singleton births in Jefferson County from 2012 to 2023. Doula exposure was defined as documented use of BirthWell Partners’ doula services. Outcomes included preterm birth (< 37 weeks), low birth weight (< 2500 g), very low birth weight (< 1500 g), breastfeeding initiation, and c-section delivery. We estimate multiple models with year and month fixed effects and control for maternal and pregnancy characteristics. We also calculate net monetary benefits using the average first‑year Medicaid costs of premature versus full-term births in Alabama. The analytic sample included 42,285 Medicaid singleton births (730 with doula services; 41,555 without). In linear probability models, doula services were associated with lower preterm birth (− 4.4% points), low birthweight (− 3.0 pp), and very low birthweight (− 1.4 pp), higher breastfeeding initiation (+ 8.6 pp), and fewer c-section deliveries (− 5.3 pp) (all p ≤ 0.01). At a willingness‑to‑pay threshold of $1,500 per additional full‑term birth, the estimated monetary benefit was $2,669, yielding a net monetary benefit of $1,170 after subtracting a $1,500 doula cost; when accounting for mother characteristics the net monetary benefit rises to $1278 (in 2023 dollars). Doula services in a Medicaid population were associated with clinically meaningful improvements in birth outcomes and with positive net monetary benefits. These findings provide state-level evidence relevant to Medicaid reimbursement models that expand access to doula care for disadvantaged populations.