Why a doula?


Research: The most recent meta-analysis conducted by the Cochrane Review concluded “Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have [doula] support throughout labour and birth.”  Hodnett ED, Gates S, Hofmeyr GJ, Sakala C, Weston J. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2013, Issue 7

Continuous Support for Women During Childbirth

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of
Systematic Reviews 2013, Issue 7. Ar t. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub5.
Historically women have bee n attended and supported by other women during labor and birth. However in many countries, as more
women are giving birth in hospital rather than at home, continuous support during labor has become the exception rather than
the norm. This may contribute to the dehumanisation of womens childbirth experiences.The review of studies included 23 trials (22
providing data), from 16 countries, involving 15,288 women in a wide range of settings and circumstances. The continuous
support was provided either by hospital staff (such as nurses or midwives), women who were not hospital employees and had no
personal relationship to the laboring woman (such as doulas or women who were provided with a modest amount of guidance), or by
companions of the womans choice from her social network (such as her husband, partner, mother, or friend). Women who received
continuous labor support were more likely to give birth spontaneously, i.e. give birth with neither caesarean nor vacuum nor forceps.
In addition, women were less likely to use pain medications, were more likely to be satisfied, and had slightly shorter labors. Their
babies were less likely to have low five-minute APGAR scores. No adverse effects were identified. We conclude that all women should
have continuous support during labor. Continuous support from a person who is present solely to provide support, is not a member
of the womans social network, is experienced in providing labor support, and has at least a modest amount of training [i.e. a doula], appears to be
most beneficial In comparison with having no companion during labor.

Overdue: Medicaid and Private Insurance Coverage of Doula Care to Strengthen Maternal and Infant Health

This January 2016 issue brief published by the National Partnership for Women and Families, and Childbirth Connections outlines the cost benefits of coverage for Birth Doula services. “Because the benefits are particularly significant for those most at risk of poor outcomes, doula support has the potential to reduce health disparities and improve health equity. Doula programs in underserved communities have had positive outcomes and are expanding, but the persistent problem of unstable funding limits their reach and impact.

In August 2013, the Centers for Medicare and Medicaid Services (CMS) Expert Panel on Improving Maternal and Infant Health Outcomes in Medicaid/CHIP included providing coverage for continuous doula support during labor among its recommendations.”



Zhang, Jun MB, PhD; Bernasko, James W. MB, ChB; Leybovich, Etel; Fahs, Marianne PhD; Hatch, Maureen C. PhD.
Obstetrics & Gynecology. 88(4, Part 2):739-744, October 1996.

Meta-analysis of four studies conducted among young, low-income, primiparous women who gave birth on a busy labor floor in the absence of a companion suggested that continuous labor support by a labor attendant [such as a doula] shortens the duration of labor by 2.8 hours (95% confidence interval [CI] 2.2-3.4), doubles spontaneous vaginal birth (relative risk [RR] 2.01, 95% CI 1.5-2.7) and halves the frequency of oxytocin use (RR 0.44, 95% CI 0.4-0.7), forceps use (RR 0.46, 95% CI 0.3-0.7), and cesarean delivery rate (RR 0.54, 95% CI 0.4-0.7). Women with labor support also reported higher satisfaction and a better postpartum course.

Conclusion: Labor support may have important positive effects on obstetric outcomes among young, disadvantaged women.

“Going Beyond the Call of Doula”: A Grounded Theory Analysis of the Diverse Roles Community-Based Doulas Play in the Lives of Pregnant and Parenting Adolescent Mothers. Fall 2010 Issue of The Journal of Perinatal Education. Click here to read this ground breaking study.

“…The ethnographic findings of this study suggest that the doulas provide valuable assistance to pregnant and parenting adolescents by addressing social psychological issues and socio-economic disparities. ‘‘Diverse role-taking’’ results in doulas helping pregnant adolescents navigate more successfully through fragmented social and health service systems that are less supportive of low-income adolescents, who are often perceived to be draining scarce resources. The findings have implications for the roles of community-based doulas assigned to low income adolescents of color seeking to overcome obstacles and attain better educational and economic opportunities.”

Doula Care, Early Breastfeeding Oucomes, and Breastfeeding Status at 6 Weeks Postpartum Among Low-Income Primiparae

Nommsen-Rivers LA, Mastergeorge AM, Hansen RL, Cullum AS, Dewey KG.
JOGNN, 38, 157-173; 2009.

OBJECTIVE: To examine associations between doula care, early breastfeeding outcomes, and breastfeeding duration.PARTICIPANTS: Low-income, full term primiparae receiving doula care (n=44) or standard care (n=97).

MEASURES: Birth outcomes and newborn feeding data obtained from the hospital record. Follow-up interviews conducted at day 3 to record the timing of onset of lactogenesis and breastfeeding behavior and at 6 weeks to obtain current breastfeeding status.

RESULTS: Adjusting for baseline differences, women receiving doula care were significantly more likely to have a short stage II labor, a noninstrumental vaginal delivery, and to experience onset of lactogenesis within 72 hours postpartum (timely onset of lactogenesis). Overall, 68% of women receiving doula care and 54% of women receiving standard care were breastfeeding at 6 weeks. In the subset with a prenatal stressor (n=63), the doula care group was more than twice as likely to be breastfeeding at 6 weeks (89% vs. standard care, 40%). Breastfeeding at 6 weeks was also significantly associated with timely onset of lactogenesis and maternal report that the infant “sucked well” at day 3.

CONCLUSIONS: Doula care was associated with improved childbirth outcomes and timely onset of lactogenesis. Both directly and as mediated by timely onset of lactogenesis, doula care was also associated with higher breastfeeding prevalence at 6 weeks.


Postpartum depression and companionship in the clinical birth environment: a randomized, controlled study.

Wolman WL1, Chalmers B, Hofmeyr GJ, Nikodem VC. Am J Obstet Gynecol. 1993 May;168(5):1388-93.
Of 189 first time mothers laboring in a familiar community hospital, 92 were allocated by randomized, sealed envelopes to receive additional companionship from one of three volunteer labor companions recruited from the community [community doulas].
The group receiving support attained higher self-esteem scores and lower postpartum depression and anxiety ratings 6 weeks after delivery.CONCLUSION: In the clinical labor environment companionship modifies factors that contribute to the development of postnatal depression. We emphasize the importance of paying attention to the psychosocial environment in which labor takes place, to facilitate adaptation to parenthood.

The Effect of a Supportive Companion on Perinatal Problems, Length of Labor, and Mother-Infant Interaction.

N Engl J Med. 1980 Sep 11;303(11):597-600.


We studied the effects of a supportive lay woman (“doula”) on the length of labor and on mother-infant interaction after delivery in healthy Guatemalan primigravid women. Initial assignment of mothers to the experimental (doula) or control group was random, but controls showed a higher rate (P less than 0.001) of subsequent perinatal problems (e.g. cesarean section and meconium staining). It was necessary to admit 103 mothers to the control group and 33 to the experimental group to obtain 20 in each group with uncomplicated deliveries. In the final sample, the length of time from admission to delivery was shorter in the experimental group (8.8 vs. 19.3 hours, P less than 0.001). Mothers who had a doula present during labor were awake more after delivery (P less than 0.02) and stroked (P less than 0.001), smiled at (P less than 0.009), and talked to (P less than 0.002) their babies more than the control mothers. These observations suggest that there may be major perinatal benefits of constant human support during labor.

Minnesota Finds Doula Care for Low-Income Women Could Save Taxpayers Money

A new study led by Dr. Katy Backes Kozhimannil, assistant professor at the University of Minnesota School of Public Health, found lower cesarean birth rates and lower preterm birth rates among Medicaid beneficiaries with access to support from a birth doula than among Medicaid patients nationally. A doula is not a medical provider, but is a trained, experienced professional person who can provide information, physical assistance, and support to a woman during childbirth.

The research indicates that policy changes to provide Medicaid coverage for birth doulas may actually decrease costs due to lower rates of cesarean births among Medicaid patients with doula support. Support during childbirth may be especially important for women with low health literacy or patients whose first language is not English and who may not fully understand all their clinical options during childbirth.

Positive health impacts of continuous labor support are well documented, but this is the first analysis of the potential financial impact of offering insurance coverage for that type of support.

The results are published online February 2013 in the American Journal of Public Health, download a copy here

Just Another Day in a Woman’s Life? Women’s Long-Term Perceptions of Their First Birth Experience.

Simkin, P. (Birth 19:4 December 1991)

Penny Simkin’s ground breaking study showed that women remember their birth experience in minute detail, even 20 years after the event. She shows that this experience has long term impacts on a woman’s life.

“The way a woman is treated by the professionals on whom she depends may largely determine how she feels about the experience for the rest of her life. A Woman in labor is highly vulnerable….. If she is treated without respect, if her efforts to maintain dignity and control are rebuffed, or if she is taken advantage of, the negative impact is permanent. If she is nurtured, treated with kindness and respect, and feels like a participant, the positive impact is permanent…”
t is clear that the birth experience has a powerful effect on women with a potential for permanent or long-term positive or negative impact…. The potential for psychological benefits or damage is present at every birth.”

Read the entire article here.