All About Doulas

Discover the medical literature and evidence based care says about doula support during labor

Hodnett ED, Gates S, Hofmeyr G J, Sakala C. Continuous support for women during childbirth. The Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003766. http://www.cochrane.org/Cochrane/revabstr/AB003766.htm

The Cochrane Database of Systematic Reviews conducted a meta-analysis of 15 good-quality studies on continuous labor support involving nearly 13,000 women. Results showed that women who had continuous one-to-one support during labor were less likely to:

1. have regional analgesia/anesthesia (6 trials, n = 10048; relative risk (RR) = 0.90, 95% confidence interval (CI) 0.81 to 0.99);

2. have any analgesia/anesthesia (11 trials, n = 11051; RR = 0.87, 95% CI 0.79 to 0.96

3. have an operative vaginal birth (14 trials, n = 12757; RR = 0.89, 95% CI 0.83 to 0.96)

4. have a cesarean birth (15 trials, n = 12791; RR = 0.90, 95% CI 0.82 to 0.99)

5. report dissatisfaction with or negative rating of the childbirth experience (6 trials, n = 9824; RR = 0.73, 95% CI 0.65 to 0.83)

6. they were more likely to have a spontaneous vaginal birth (14 trials; n = 12757; RR = 1.08, 95% CI 1.04 to 1.13).

There are significant flaws in the Cochrane review, however. For example, the reviews combined studies that had hospital staff acting in the role as doula, together with non-hospital staff. We know from studies that have analyzed this factor, that whether or not the doula is employed by the hospital, or has a medical background, does make a difference to the overall outcomes. In addition, the review combined healthy term pregnancies together with studies that only looked at very premature babies. This will clearly have an impact on the overall rates of intervention and outcomes of birth.

Controlling for these differences in the meta-analysis would have shown even greater benefit of doula support, as the Cochrane reviewers themselves admit: "in general, continuous intrapartum support was associated with greater benefits when the provider was not a member of the hospital staff, when it began early in labour, and in settings in which epidural analgesia was not routinely available."

Individual studies which have examined the effect of doula support have reflected this greater impact:

Hofmeyr, G.J., Nikodem, V.C., & Wolmen, W., 1991, ‘Companionship to modify the clinical birth environment: Effects on progress and perceptions of labor and breastfeeding’, British Journal of Obstetrics & Gynaecology, vol. 98, pp. 756-764.

Randomized controlled trial. Companionship in labor resulted in significantly less use of analgesia, and were more likely to be breastfeeding at 6 weeks (51% versus 29%, p = 0.01)

Kennell, J.H., Klaus, M., & McGrath, S.K., 1991, ‘Continuous emotional support during labor in a US hospital’, JAMA, vol. 265, pp. 2197-2201.

Randomized controlled trial with 412 women. Continuous doula support reduced risk of cesarean (8% versus 18%), forceps deliveries, epidural anesthesia for spontaneous vaginal birth (7.8% versus 55.3%), oxytocin use, duration of labor, prolonged infant hospitalization, and maternal fever.

Kennell, J.H., & McGrath, S.K., 1993, ‘Labor support by a doula for middle-income couples: the effect on cesarean rates’, Pediatric Res., vol. 33, no. 12A.

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Klaus, M., Kennell, J.H., & Robertson, S.S., 1986, ‘Effects of social support during parturition on maternal and infant morbidity’, British Medical Journal, vol. 293, pp. 585-587.

Randomized controlled trial. Women who had doula support had reduced likelihood of cesarean section (7% vs. 17%, p less than 0.01) and oxytocin augmentation (2% vs. 13%, p less than 0.001), and fewer infants admitted to intensive care (p less than 0.10).

McGrath, S.K., Kennell, J.H., & Suresh, M., 1999, ‘Doula support vs. epidural analgesia: Impact on cesarean rates’, Pediatric Res, vol. 45, no. 16A.

Randomized controlled trial with 531 primigravidas. Compared perinatal effects of epidural anesthesia with continuous doula support. Women with doula support had lower cesarean rates, less use of analgesia, less use of oxytocics, lower risk of maternal fever, and lower risk of assisted delivery (forceps or vacuum).

Hofmeyr, G.J., Nikodem, V.C., & Wolmen, W., 1991, ‘Companionship to modify the clinical birth environment: Effects on progress and perceptions of labor and breastfeeding’, British Journal of Obstetrics & Gynaecology, vol. 98, pp. 756-764.

Randomized controlled trial. Companionship in labor resulted in significantly less use of analgesia, and were more likely to be breastfeeding at 6 weeks (51% versus 29%, p = 0.01)

Sosa, R., Kennell, J.H., & Klaus, M., 1980, ‘The effect of a supportive companion on perinatal problems, length of labor, and mother interaction’, New England Journal of Medicine, vol. 303, pp. 597-600.

The presence of a doula shortened the duration of labor from an average 19.3 hours in the control group to 8.8 hours. Women with doula support also had lower risk of cesarean section or meconium staining.