There is evidence to show that having a doula can mean:

Reduced risk of Caesarean birth † *.
Reduced risk of instrumental birth † *.
Reduced need for painkillers or epidural during birth † *.
Reduced rate of induction of labour † *.
Shorter labour †.
Increased parental satisfaction with the birth experience. †
Increased likelihood of initiating breastfeeding *.
Increased likelihood of successfully establishing breastfeeding & breastfeeding at 6 weeks *.
Lower incidence of depressive symptomatology †.
Improve equity and provide culturally responsive care#

* Brigstocke S. MIDIRS Midwifery Digest, vol 24, no 2, 2014, pp 157-160

#Meghan A Bohren and Sarah Chapman Cochrane review
† Hodnett ED, Gates S, Hofmeyr G, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub5 and Bohren MA, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2017, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub6.

New Evidence in Support of Doulas

Published March 2019: ‘What is a doula and what do they do?’

Co-authored by Meghan A. Bohren and Sarah Chapman

This blog is an extract from an article originally published in The Conversation you can read the full article here.

Women have traditionally been supported by a companion during childbirth, and there is good evidence this benefits both the woman and the baby.

The World Health Organisation recommends continuous support for women during childbirth. Yet across the world, initiatives promoting health facilities as the safest place to give birth have not necessarily respected this tradition.

But now we have new evidence on the ways women are supported during childbirth by a doula or other labour companion.

Our research has found labour companions (including doulas, partners, and family members) support women during childbirth by providing information, advocating for the woman’s needs, and providing practical and emotional support.

Importantly, our research also indicates pairing a woman with a doula from the same ethnic, linguistic or religious background as her may be an important way to improve equity and provide culturally responsive care.

What is doula care?

The word “doula” comes from a Greek word meaning “woman’s servant”.

Doulas are trained, non-medical professionals who provide continuous physical, emotional, and informational support to women before, during and after childbirth, to facilitate the best possible birth experience.

Doulas typically meet with a woman (and sometimes her partner or family) during pregnancy to help her to prepare for childbirth, build rapport, manage expectations and provide evidence-based resources.

When a woman goes into labour, she alerts her doula. The doula supports the woman throughout labour and childbirth. This is typically at a birthing clinic or hospital (some doulas may also attend home births).

Four ways to support women during labour

Our Cochrane review, published this week, (March 18^th 2019) brings together data from 51 studies across 22 countries looking at support provided by labour companions, including doulas.

First, we found through providing information, labour companions bridge communication gaps between health workers, such as doctors and midwives, and the woman. They keep her informed about the process of childbirth and her progress through labour. They may also provide her with tips around effectively using non-pharmacological pain relief, such as meditation or relaxation.

Second, labour companions advocate for the woman, speaking up in support of her and her preferences.

Third, labour companions provide practical support, which could include encouraging the woman to move around, providing massage, and holding her hand.

And finally, labour companions offer emotional support, helping the woman to feel in control and confident by praising and reassuring her, and providing a continuous physical presence.

Improved outcomes for mums and babies

The benefits of continuous support during labour and birth were highlighted in an earlier Cochrane review, which analysed data from 26 studies across 17 countries involving more than 15,000 women.

Continuous support was provided by a woman’s partner, family member, or friend; hospital staff (student midwives); or a doula.

The review found continuous support could improve several health outcomes for both the woman and her baby. Women may be more likely to have a vaginal birth (without the need for caesarean, forceps or vacuum extraction).

In addition, women who receive continuous support may be less likely to use pain medications, may have shorter labours, and may be more likely to be satisfied with their birth experience.

The babies of women who receive continuous support may be less likely to have low five-minute Apgar scores, which assess babies’ health and well-being at birth and shortly afterwards.

Supporting women to have a labour companion or doula of her choice during childbirth is an effective way to improve health outcomes, and is an important component of respectful maternity care.

Labour companionship and doula support may increase equity directly through improved women’s empowerment and provision of culturally responsive care, and indirectly by reducing the over-medicalisation of childbirth.

Research Papers

This is a selection of the research papers published on doula support.

Analyses/Reviews

Meghan A Bohren, G Justus Hofmeyr, Carol Sakala, Rieko K Fukuzawa, Anna Cuthbert. Continuous support for women during childbirth Cochrane Database of Systematic Reviews 2017. Available here

Hodnett ED, Gates S, Hofmeyr G, Sakala C. Continuous support for women during childbirth Cochrane Database of Systematic Reviews 2013. Available here

Hodnett, ED., Gates, S., Hofmeyr, GJ. & Sakala, C. Continuous support for women during childbirth Cochrane Database of Systematic Reviews 2007, Issue 3. Download paper (PDF) here.

Keenan, P. Benefits of massage therapy and use of a doula during labor and childbirth Alternative Therapies in Health & Medicine Jan 2000, 6(1), pp.66-74. Abstract available here.

Rosen, P. Supporting women in labor: analysis of different types of caregivers Journal of Midwifery & Women’s Health Jan-Feb 2004, Vol 49(1), pp.24-31. Abstract available here.

Yogev, S. Support in Labour: a literature review MIDIRS Midwifery Digest 2004, 14(4), pp.486-492

Birth & Postnatal related

Brigstocke S. MIDIRS Midwifery Digest, vol 24, no 2, 2014, pp 157-160

Harris SJ1, Janssen PA, Saxell L, Carty EA, MacRae GS, Petersen KL. CMAJ. Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes. 2012 Nov 20;184(17):1885-92. doi: 10.1503/cmaj.111753. Epub 2012 Sep 10. Abstract available here.

Goedkoop V. MIDIRS Midwifery Digest, vol 19, no 2, June 2009, pp 217-218

Birth related

Kozhimannil KB1, Attanasio LB, Jou J, Joarnt LK, Johnson PJ, Gjerdingen DK. Potential benefits of increased access to doula support during childbirth. The American Journal of Managed Care. 2014 Aug 1;20(8):e340-52.Abstract available here.

Masoudi Z1, Akbarzadeh M2, Vaziri F1, Zare N3, Ramzi M4. The effects of decreasing maternal anxiety on fetal oxygenation and nucleated red blood cells count in the cord blood. Iranian Journal of Pediatrics. 2014 Jun;24(3):285-92. Abstract available here

Amram NL, Klein MC, Mok H, Simkin P, Lindstrom K, Grant J. How birth doulas help clients adapt to changes in circumstances, clinical care, and client preferences during labor. The Journal of Perinatal Education . 2014 Spring;23(2):96-103. doi: 10.1891/1058-1243.23.2.96. Abstract available here

Ballen, LE. & Fulcher, AJ. Nurses and doulas. Complementary roles to provide optimal maternity care Journal of Obstetric, Gynecologic, and Neonatal Nursing 2006, 35, pp.304–311 Abstract available here.

Berg, M. & Terstad, A. Swedish women’s experiences of doula support during childbirth Midwifery 2006, 22(4), pp.330-338

Campbell, D., Scott, KD., Klaus, MH. & Falk, M. Female Relatives or Friends Trained as Labor Doulas: Outcomes at 6 to 8 Weeks Postpartum. Birth Sept 2007, Vol 34(3), pp.220–227. Abstract available here.

Campbell, DA., Lake, MF., Falk, M. & Backstrand, JR. A randomized control trial of continuous support in labor by a lay doula Journal of Obstetric, Gynecologic & Neonatal Nursing 2006, 35, pp.456–464. Abstract available here.

Khreisheh, R. Support in the first stage of labour from a female relative: the first step in improving the quality of maternity services Midwifery 2009 (Article in Press). Abstract available here.

Lundgren, I. Swedish women’s experiences of doula support during childbirth Midwifery April 2010, Vol 26(2), pp.173-180

Martin, T., Stein, JH., Kennell, JH. & Fulcher, A. Benefits of a Doula Present at the Birth of a Child Pediatrics 2004, 114(5), pp.1488-1491. Download paper (PDF) here.

McGrath, SK. & Kennel, JH. A Randomized Controlled Trial of Continuous Labor Support for Middle-Class Couples: Effect on Cesarean Delivery Rates Birth 2008, 35(2), pp.92-97. Abstract available here.

Trueba, G., Contreras, C., Velazco, MT., Lara, EG. & Martínez, HB. Alternative Strategy to Decrease Cesarean Section: Support by Doulas During Labor Journal of Perinatal Education Spring 2000, 9(2), pp.8-13. Abstract available here.

Postnatal related

Gjerdingen DK1, McGovern P, Pratt R, Johnson L, Crow S. Postpartum doula and peer telephone support for postpartum depression: a pilot randomized controlled trial. J Prim Care Community Health. 2013 Jan;4(1):36-43. doi: 10.1177/2150131912451598. Epub 2012 Jun 20. Abstract available here.

McComish, JF. & Visger, JM. Domains of Postpartum Doula Care and Maternal Responsiveness and Competence Journal of Obstetric, Gynaecologic & Neonatal Nursing Mar/Apr 2009, Vol 38(2), pp.148-156. Abstract available here.

Goldbort, J. Postpartum depression: Bridging the gap between medicalized birth and social supportInternational Journal of Childbirth Education December 2002. Abstract available here.

Breastfeeding related

Edwards RC1, Thullen MJ, Korfmacher J, Lantos JD, Henson LG, Hans SL. Breastfeeding and complementary food: randomized trial of community doula home visiting. Pediatrics. 2013 Nov;132 Suppl 2:S160-6. doi: 10.1542/peds.2013-1021P. Abstract available here.

Kozhimannil KB1, Attanasio LB, Hardeman RR, O’Brien M. Doula care supports near-universal breastfeeding initiation among diverse, low-income women. J Midwifery Womens Health. 2013 Jul-Aug;58(4):378-82. doi: 10.1111/jmwh.12065. Epub 2013 Jul 9. Abstract available here.

Mottl-Santiago, J., Walker, C., Ewan, J., Vragovic, O., Winder, S. & Stubblefield, P. A hospital-based doula program and childbirth outcomes in an urban, multicultural setting Maternal and Child Health Journal May 2008, Vol 12(3), pp.372-377. Abstract available here.

Fathers/partners & family related

Thullen MJ1, McMillin SE, Korfmacher J, Humphries ML, Bellamy J, Henson L, Hans S. Father participation in a community-doula home-visiting intervention with young, african american mothers. Infant Ment Health J. 2014 Sep;35(5):422-34. doi: 10.1002/imhj.21463. Epub 2014 Aug 25. Abstract available here

Key studies from pre-2000

Hofmeyr, GJ., Nikodem, VC., Wolman, W., Chalmers, BE. & Kramer, T. Companionship to modify the clinical birth environment: Effects on progress and perceptions of labour and breastfeeding British Journal of Obstetrics & Gynaecology Aug 1991, 98, pp.756–764. Abstract available here.

Kennell, JH., Klaus, MH., McGrath, S., Robertson, S. & Hinkley, C. Continuous emotional support during labor in a US hospital: A randomized controlled trial. Journal of the American Medical Association May 1991, 265(17), pp.2197-201. Abstract available here.

Klaus, MH. & Kennell, JH. The doula: an essential ingredient of childbirth rediscovered. Acta Paediatrica 1997, 86(10), pp.1034–1036. Abstract available here.

Klaus MH, Kennell JH, Robertson SS, Sosa R. Effects of social support during parturition on maternal and infant morbidity British Medical Journal 1986; 293:585–587. Abstract available here.

Langer, A., Campero, L., Garcia, C. & Reynoso, S. Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers’ wellbeing in a Mexican public hospital: a randomised clinical trial British Journal of Obstetrics & Gynaecology Oct 1998, 105(10), pp.1056-63. Abstract available here.

Madi, BC., Sandall, J., Bennett, R. & MacLeod, C. Effects of female relative support in labour: a randomised controlled trial Birth 1999; 26(1), 4-8. Abstract available here.

Scott, KD., Klaus, PH., & Klaus, MH. The obstetrical and postpartum benefits of continuous support during childbirth Journal of Women’s Health Gender Based Medicine Dec 1999, 8(10), pp.1257-64. Abstract availablehere.

Wolman, WL., Chambers, B., Hofmeyr, GJ. & Nikodem, V. Post-partum depression and companionship in the clinical birth environment: A randomized, controlled study American Journal of Obstetrics & Gynaecology 1993, 168, pp.1380–1393. Abstract available here.