The Evidence for Doulas
What is a doula?
According to DONA International, a doula is a professional who is trained in childbirth and provides continuous support to a mother before, during, and just after birth (postpartum doulas are not covered in this article). Doula comes from a Greek word that means “a woman who serves” or “handmaiden.”
How many women use doulas?
In a 2006 survey that took place in the U.S., only 3% of women said they used a doula during childbirth (Declerq et al., 2007).
What do doulas do?
Doulas “mother the mother.” While performing her role, a doula:
- Provides emotional support
- Uses comfort measures: breathing, relaxation, movement, positioning
- Gives information
- Continuously reassures and comforts the mother (the key word is continuous—a doula never leaves the mother’s side)
- Helps a mother become informed about various birth choices
- Advocates for the mother and helps facilitate communication between the mother and care provider
- Looks after your partner as well (gives them bathroom breaks!), but their primary responsibility is to the mother
It’s also important for you to understand what doulas do NOT do:
- Doulas are NOT medical professionals
- They do not perform clinical tasks such as vaginal exams or fetal heart monitoring
- They do not give medical advice or diagnose conditions
- They do not judge you for decisions that you make
- They do not let their personal values or biases get in the way of caring for you (for example, they should not pressure you into making any decisions just because that’s what they prefer)
- They do not take over the role of your husband or partner
- They do not deliver the baby
- They do not change shifts
You can read more about what doulas do and do not do in the DONA International’s standard of practice for birth doulas written here.
How is a doula different from a labor and delivery nurse or partner/spouse?
The most important thing a woman needs during labor is continuous support. This means that you have someone by your side continuously from start to finish. A doula never leaves your side. Nurses have many other responsibilities other than you. Aside from helping care for you, the nurse is communicating with your care provider, taking care of other patients, documenting care, taking breaks, and taking care of other responsibilities. A nurse’s support ends when her shift does. The doula only has one obligation the whole time she is with you—and that is YOU!
Sometimes people think that they don’t need a doula because their partner will be with them continuously throughout labor. Your partner is an essential support person for you to have by your side. However, your partner will need to eat and use the bathroom at times. Also, most partners have limited knowledge about birth, medical procedures, or what goes on in a hospital. Doulas and partners can work together to make up a labor support team. To read a husband’s perspective on hiring a doula, read this article from Bloom in Spokane, Washington.
So what is the evidence for doulas?
In 2012, Hodnett et al. published an updated Cochrane review on the use of continuous support for women during childbirth. They pooled the results of 22 trials that included more than 15,000 women. These women were randomized to either receive continuous, one-on-one support during labor or “usual care.” The quality of the studies was good.
Continuous support was provided either by a member of the hospital staff, such as a midwife or nurse (9 studies), women who were not part of the woman’s social network and not part of hospital staff (doula 5 studies; childbirth educators 1 study, retired nurses 1 study), or a companion of the woman’s social network such as a female relative or the woman’s partner (6 studies). In 11 studies, the husband/partner was not allowed to be present at birth, and so continuous support was compared to no support at all. In all the other studies, the husband or partner was allowed to be present in addition to the person providing continuous labor support.
Overall, women who received continuous support were more likely to have spontaneous vaginal births and less likely to have any pain medication, epidurals, negative feelings about childbirth, vacuum or forceps-assisted births, and C-sections. In addition, their labors were shorter by about 40 minutes and their babies were less likely to have low Apgar scores at birth.
What does this mean?
It means that if you have continuous labor support (that is, someone who never leaves your side), you are statistically more likely to have better outcomes and your baby is more likely to have better outcomes!
How did doulas compare to the other types of continuous support?
The researchers also looked to see if the type of support made a difference. They wanted to know—does it matter who you choose for your continuous support? Does it matter if you choose a midwife, doula, or partner for your continuous support? They were able to look at this question for 6 outcomes: use of any pain medication, use of Pitocin during labor, spontaneous vaginal birth, C-section, admission to special care nursery after birth, and negative ratings of birth experience.
For most of these outcomes,* the best results occurred when woman had continuous labor support from a doula— someone who was NOT a staff member at the hospital and who was NOT part of the woman’s social network. When continuous labor support was provided by a doula, women experienced a:
- 31% decrease in the use of Pitocin*
- 28% decrease in the risk of C-section*
- 12% increase in the likelihood of a spontaneous vaginal birth*
- 9% decrease in the use of any medications for pain relief
- 14% decrease in the risk of newborns being admitted to a special care nursery
- 34% decrease in the risk of being dissatisfied with the birth experience*
For four of these outcomes,* results with a doula were better than all the other types of continuous support that were studied. For the other outcomes, there was no difference between types of continuous support.
Why are doulas so effective?
There are 3 main reasons why we think doulas are so effective. The first reason is the “harsh environment” theory. In most developed countries, ever since birth moved out of the home and into the hospital, women have been giving birth in conditions that can often be described as harsh. In the hospital, laboring women are frequently submitted to institutional routines, high intervention rates, personnel who are strangers, lack of privacy, bright lighting, and needles. Most of us would have a hard time dealing with these conditions when we’re feeling our best. But women in labor to deal with these harsh conditions when they are in their most vulnerable state. These harsh conditions may slow down a woman’s labor and decrease the woman’s self-confidence. It is thought that a doula “buffers” this harsh environment by providing continuous support and companionship which promotes the mother’s self-esteem (Hofmeyr, Nikodem et al. 1991).
The third reason that doulas are effective is because doulas are a form of pain relief (Hofmeyr, 1991). With continuous support, women are less likely to request epidurals or pain medication (Hodnett, 2011). Why are women with doulas less likely to request pain medications? Well, women are less likely to request pain medications when they have a doula because they just don’t need an epidural as much! Women who have a doula are statistically more likely to feel less pain when a doula is present. Furthermore, by avoiding epidural anesthesia, women may avoid many medical interventions that often go along with an epidural, including Pitocin augmentation and continuous electronic fetal monitoring (Caton, Corry et al. 2002).
Based on reading the evidence, I have come up with a conceptual model of how doulas support influences outcomes.
A conceptual model is what researchers use to try and understand how a phenomenon works. Here is my conceptual model on the phenomenon of doula support. This model has already been translated into several different languages– please contact me if you would like to translate it into your native language.
How do I find a doula?
If you’re at all on the fence about hiring a doula, you may want to interview several doulas with your partner. Childbirth Connection has a great list of interview questions for a doula. They also have a list of websites that you can use to find doulas in your area.
So what is the bottom line?
Evidence shows that the most important thing is for women to have continuous labor support from someone– whether that person is a nurse, midwife, partner, or doula. However, with several birth outcomes, doulas have a stronger effect than other types of support persons.
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You may also want to read:
Caton, D., M. P. Corry, et al. (2002). “The nature and management of labor pain: executive summary.” Am J Obstet Gynecol 186(5 Suppl Nature): S1-15.
Declercq ER, Sakala C, Corry MP, Applebaum S. (2007). “Listening to mothers II: Report of the second national U.S. survey of women’s childbearing experiences.” The Journal of Perinatal Education 16:9-14.
Hodnett, E. D. (2002). “Pain and women’s satisfaction with the experience of childbirth: a systematic review.” Am J Obstet Gynecol 186(5 Suppl Nature): S160-172.
Hodnett, E. D., S. Gates, et al. (2012). “Continuous support for women during childbirth.” Cochrane database of systematic reviews: CD003766.
Hofmeyr, G. J., V. C. Nikodem, et al. (1991). “Companionship to modify the clinical birth environment: effects on progress and perceptions of labour, and breastfeeding.” British journal of obstetrics and gynaecology 98(8): 756-764.