A mixed methods economic analysis of doula-service enhanced maternity care as compared with standard maternity care

BACKGROUND: In the United States, racial and income disparities in maternity care outcomes are large and persistent. Research demonstrates that community doulas (specialized community health workers for pregnant, birthing and postpartum people) can improve maternal and infant outcomes. Despite this evidence, doulas have not yet been widely adopted in health services for low-income communities. One barrier to scale-up is understanding the costs and benefits of integrating doula services into maternity care payment systems. METHODS: An exploratory, sequential mixed methods study design was used to understand decision-maker perspectives on doulas in maternity care and apply these priorities to an economic evaluation of a randomized trial of enhanced doula support. 16 in-depth, semi-structured interviews with Medicaid, Accountable Care Organization (ACO) and maternity care decision makers in Massachusetts were conducted. Results from the qualitative study informed the design of an economic analysis of a pragmatic trial of doula support. A return on investment analysis, with a focus on areas of high financial impact and organized by segments of health care services was conducted. Program costs were analyzed using a micro-costing approach. Hospital data on health care costs and payments were used to calculate financial outcomes for both intervention and control groups. Sensitivity and sub-group analyses were developed to understand variations in impact for different populations, settings and doula program models. RESULTS: Decision-maker interviews revealed that health care organizations prioritize investments that promote improved population health, patient experience, cost reduction, and elimination of racial disparities in outcomes. Participants universally expressed interest in an analysis approach that provides information on return-on-investment outcomes, as well as the clinical and cost areas with the largest impact. The time frame of interest was primarily in the pregnancy and newborn episodes of care, with some participants expressing interest in longer term outcomes related to fewer first cesarean deliveries or preterm birth. The economic analysis found an 18% return on investment for the Best Beginnings for Babies doula intervention overall. Sensitivity analyses demonstrated the largest impact was for people with medical and social risk factors and for those who received at least 5 hours of prenatal home visits, as well as labor support. CONCLUSION: Medicaid and maternity care decision-makers are supportive of doula programs if they are affordable and can create cost savings. An economic analysis of the Birth Sisters Best Beginnings for Babies program found a positive return on investment, benefiting both health care payers and families. Community doula programs are a high-value innovation that should be reimbursed by Medicaid agencies.2021-09-25T00:00:00

Reducing cell intrinsic immunity to mRNA vaccine alters adaptive immune responses in mice

The response to mRNA vaccines needs to be sufficient for immune cell activation and recruitment, but moderate enough to ensure efficacious antigen expression. The choice of the cap structure and use of N1-methylpseudouridine (m1Ψ) instead of uridine, which have been shown to reduce RNA sensing by the cellular innate immune system, has led to improved efficacy of mRNA vaccine platforms. Understanding how RNA modifications influence the cell intrinsic immune response may help in the development of more effective mRNA vaccines. In the current study, we compared mRNA vaccines in mice against influenza virus using three different mRNA formats: uridine-containing mRNA (D1-uRNA), m1Ψ-modified mRNA (D1-modRNA), and D1-modRNA with a cap1 structure (cC1-modRNA). D1-uRNA vaccine induced a significantly different gene expression profile to the modified mRNA vaccines, with an up-regulation of Stat1 and RnaseL, and increased systemic inflammation. This result correlated with significantly reduced antigen-specific antibody responses and reduced protection against influenza virus infection compared with D1-modRNA and cC1-modRNA. Incorporation of m1Ψ alone without cap1 improved antibodies, but both modifications were required for the optimum response. Therefore, the incorporation of m1Ψ and cap1 alters protective immunity from mRNA vaccines by altering the innate immune response to the vaccine material

Multisite implementation of trained volunteer doula support for disadvantaged childbearing women: a mixed-methods evaluation

Our study looked at five schemes in England which offer support to disadvantaged women having babies. The support starts in pregnancy and goes on for 6 weeks after the baby’s birth. It is provided by specially trained volunteers (called ‘doulas’). The idea started with one of the five schemes and was then taken up by the other four, with the help of funding from the Department of Health. The philosophy behind the original doula service was to provide women with the support needed for a positive birth experience and breastfeeding. We looked at impacts on the NHS, on the women and on the volunteers and at how services had started the schemes and kept them running. Participation rates were lower than we had hoped among women and doulas; 167 women and 89 doulas completed questionnaires. However, from those who filled in questionnaires or took part in focus groups we heard that most women really appreciated the service. Where women were less pleased with the service, it was because they had not received as much support as they wanted. There was some evidence that women who had doula support had fewer caesarean sections although the numbers were not sufficient to rule out the possibility that this difference was due to chance. Women supported by doulas were more likely to start and to be continuing breastfeeding when their baby was 6 weeks old. Through questionnaires and telephone interviews we learned that most volunteers enjoyed their role and called it a privilege to support a woman at such an important time. They felt that they had learned a lot and gained confidence and some had gone on to further training. Midwives who took part in focus groups and the heads of midwifery who were interviewed were generally positive about the scheme. Starting the schemes and keeping them running: funding was a major issue that persisted for all the doula services; other challenges included ensuring a steady rate of women referred and available volunteers