Evidence for Doulas

Doulas: The Proven Way to Prevent C-Sections

In August 2014, the American Journal of Managed Care published a study by the U of Minnesota with findings that the presence of a doula in the delivery room prevents unnecessary c-sections by 80 to 90%, and reduces all c-sections by 60%! This is BIG! Click here to read the article: Potential Benefits of Increased Access to Doula Support During Childbirth.

In March 2014, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine published their Obstetric Care Consensus titled “Safe Prevention of the Primary Cesarean Delivery” in which they review the evidence supporting doula care. Here’s a direct quote:

VBAC mama and new baby!

VBAC mama
and new baby!

“Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula.   A Cochrane meta-analysis of 12 trials and more than 15,000 women demonstrated that the presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery(111).   Given that there are no associated measurable harms, this resource is probably underutilized.”


That quote from the ACOG Consensus statement on preventing c-sections referenced this journal review which states:

“Modern obstetric care frequently subjects women to institutional routines, which may have adverse effects on the progress of labour. Supportive care during labour may involve emotional support, comfort measures, information and advocacy. These may enhance physiologic labour processes as well as women’s feelings of control and competence, and thus reduce the need for obstetric intervention. … We conclude that all women should have continuous support during labour. Continuous support from a person who is present solely to provide support, is not a member of the woman’s social network, is experienced in providing labour support, and has at least a modest amount of training, appears to be most beneficial.”


In other words, you need a trained and experienced doula! A husband and/or a friend isn’t the same thing and won’t give you these results!

More studies:mamasfriend angela1

“On questionnaires the day after delivery, 100 percent of couples with doula support rated their experience with the doula positively. … For middle-class women laboring with the support of their male partner, the continuous presence of a doula during labor significantly decreased the likelihood of cesarean delivery and reduced the need for epidural analgesia.” (20) This suggests a husband alone isn’t enough!

“Eleven randomized control trials examined whether additional support by a trained lay person (called a doula), student midwife or midwife, who provides continuous support consisting of praise, encouragement, reassurance, comfort measures, physical contact and explanations about progress during labor, will affect obstetrical and neonatal outcomes. The women were healthy primigravidas [meaning, first time mothers] at term.  Meta-analysis of these studies showed a reduction in the duration of labor, the use of medications for pain relief, operative vaginal delivery, and in many studies a reduction in caesarian deliveries. At 6 weeks after delivery in one study, a greater proportion of doula-supported women were breastfeeding, reported greater self-esteem, less depression, a higher regard for their babies and their ability to care for them compared to the control mothers. Observations during labor showed that fathers remained farther away from mothers than doulas, talked and touched less. When the doula was present with the couple during labor the father offered more personal support. The father-to-be’ s presence during labor and delivery is important to the mother and father, but it is the presence of the doula that results in significant benefits in outcome.” (10, Emphasis mine)

“Our goal was to contrast the influence of intermittent and continuous support provided by doulas during labor and delivery on 5 childbirth outcomes. Data were aggregated across 11 clinical trials by means of meta-analytic techniques. Continuous support, when compared with no doula support, was significantly associated with shorter labors (weighted mean difference -1.64 hours, 95% confidence interval -2.3 to -.96) and decreased need for the use of any analgesia (odds ratio.64, 95% confidence interval.49 to.85), oxytocin (odds ratio.29, 95% confidence interval.20 to.40), forceps (odds ratio.43, 95% confidence interval.28 to.65), and cesarean sections (odds ratio.49, 95% confidence interval.37 to.65). Intermittent support was not significantly associated with any of the outcomes [ i.e., the kind of care received from a caring nurse]. Odds ratios differed between the 2 groups of studies for each outcome. Continuous support appears to have a greater beneficial impact on the 5 outcomes than intermittent support.” (1, Emphasis mine) Did you read that? They are 95% confident that having a doula as opposed to not having a doula is associated with shorter labors, decreased need for pain medications, decreased need for pitocin,  decreased need for pitocin, and decreased need for c-sections. They are *95%* confident for each of these benefits! 

“… Doula support is an essential component of childbirth. A thorough reorganization of current birth practices is in order to ensure that every woman has access to continuous emotional and physical support during labor.” (3)stephanie8

“The beneficial effects of labor support underscore the need for a review of current obstetric practices.” (2)

“Given the clear benefits and no known risks associated with intrapartum support, every effort should be made to ensure all labouring women receive support, not only from those close to them but also from specially trained caregivers. This support should include continuous presence, the provision of hands-on comfort, and encouragement.” (15, Emphasis mine) –They said “specially trained caregivers”–not your friend, your mom, your sister, or your husband. This means a doula! 

“The continuous availability of a caregiver to provide psychological support and comfort should be a key component of all intrapartum care programs, which should be designed for the effective prevention, and treatment of dystocia (non-progressive labor).” (19) –This suggests having a doula can PREVENT labor dystocia! Why aren’t doctor’s telling women this?????

“A doula provides support consisting of praise, reassurance, measures to improve the comfort of the mother, physical contact such as rubbing the mother’s back and holding her hands, explanation of what is going on during labour and delivery and a constant friendly presence. Such tasks can also be fulfilled by a nurse or midwife, but they often need to perform technical/medical procedures that can distract their attention from the mother.” (16)

“Facing unprecedented pressures to reduce expenses, many hospitals are targeting the largest single budget item – labor costs… (An) unintended consequence of nursing cutbacks may be an increased cesarean rate; the inability of pared down nursing staff to provide continuous coverage to laboring mothers is shown to increase the chance of a cesarean…Doulas clearly improve clinical and service quality; they provide an absolutely safe way to reduce cesareans and other invasive birthing interventions.” (17)

“Professionals have paid much attention to innovative technology and the many new options for monitoring and managing labor. While the technology is important, it can become so prominent that clinicians ignore both the natural aspects of labor and the non-technical needs of women in labor… Changes that support the patient in labor and reinforce the natural, physiologic process … include providing one-to-one psychological support for patients using nursing staff or doulas.” (18)

Summarizing the Benefits of Having a Birth Doula:

  1. Increased chance of spontaneous vaginal birth (6)
  2. Reduced use of pain medications (1-4,7,8, 10, 20)
  3. Reduced use of oxytocin (Pitocin) (1,2,4,6,7)
  4. Reduced duration of labor (1-6, 10)
  5. Reduced use of forceps (1,2,4,5, 10)
  6. Reduced use of vacuum extraction (4, 10)
  7. Reduced chances of getting a C-section (1-7, 10, 20, 21)
  8. Reduced levels of anxiety (4)
  9. Mothers feel more secure (14)
  10. Found to be superior to Lamaze (14)
  11. Result in a more positive birth experience (4,8,13, 20)
  12. Mothers feel more in control (9,13)
  13. Less likely for babies to have low five minute Apgar scores (10)
  14. Reduced chances of health complications and hospitalizations of baby (2,3)
  15. Reduced chances of maternal fever and infection (2)
  16. Reduced maternal bleeding following birth (5)
  17. Increased chances of successful breastfeeding (4,9-12)
  18. Reduced incidence of postpartum depression (4,10)
  19. Mothers have higher regard and increased sensitivity towards babies (4,10)
  20. Mothers reported greater self esteem (10)

mamasfriend angela5


1. Scott KD, Berkowitz G, Klaus M. A comparison of intermittent and continuous support during labor: a meta-analysis. Am J Obstet Gynecol 1999 May 180:5 1054-9.2. Kennell J, Klaus M, McGrath S, Robertson S, Hinkley C. Continuous emotional support during labor in a US hospital. A randomized controlled trial. JAMA 1991 May 1 265:17 2197-201

3. Scott KD, Klaus PH, Klaus MH. The obstetrical and postpartum benefits of continuous support during childbirth. J Womens Health Gend Based Med 1999 Dec;8:1257-64.

4. Keenan P. Benefits of massage therapy and use of a doula during labor and childbirth. Altern Ther Health Med 2000 Jan;6:66-74.

5. Wang D, Mao X, Qian S. Clinical observation on Doula delivery. Chung Hua Fu Chan Ko Tsa Chih 1997 Nov 32:11 659-61.

6. Zhang J, Bernasko JW, Leybovich E, Fahs M, Hatch MC. Continuous labor support from labor attendant for primiparous women: a meta-analysis. Obstet Gynecol 1996 Oct 88:4 Pt 2 739-44

7. Nolan M. Supporting women in labour: the doula’s role. Mod Midwife 1995 Mar 5:3 12-5.

8. Gordon NP, Walton D, McAdam E, Derman J, Gallitero G, Garrett L. Effects of providing hospital-based doulas in health maintenance organization hospitals. Obstet Gynecol 1999 Mar 93:3 422-6.

9. 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. Br J Obstet Gynaecol 1998 Oct 105:10 1056-63.

10. Klaus MH, Kennell JH. The doula: an essential ingredient of childbirth rediscovered. Acta Paediatr 1997 Oct 86:10 1034-6.

11. Raphael D. Support and variation, the needs of the breast-feeding woman. Acta Paediatr Jpn 1989 Aug 31:4 369-72.

12. Barron SP, Lane HW, Hannan TE, Struempler B, Williams JC. Factors influencing duration of breast feeding among low-income women. J Am Diet Assoc 1988 Dec 88:12 1557-61.

Helping our Mama through some contractions
Helping our Mama through some contractions

13. Campero L, García C, Díaz C, Ortiz O, Reynoso S, Langer A. ”Alone, I wouldn’t have known what to do”: a qualitative study on social support during labor and delivery in Mexico. Soc Sci Med 1998 Aug 47:3 395-403.

14. Manning-Orenstein G. A birth intervention: the therapeutic effects of Doula support versus Lamaze preparation on first-time mothers’ working models of caregiving. Altern Ther Health Med 1998 Jul 4:4 73-81.

15. Hodnett, E.D. Support from caregivers during childbirth (Cochrane Review) in Cochrane Library, Issue 2. Oxford Update Software, 1998. Updated Quarterly.

16. Care in Normal Birth: a Practical Guide. Report of a Technical Working Group. World Health Organization, 1996.

17. Coming to Term: Innovations in Safely Reducing Cesarean Rates. Medical Leadership Council, Washington D.C. 1996.

18. Reducing the Cesarean Section Rates while Maintaining Maternal and Infant Outcomes. Bruce L. Flamm et al. Institute for Healthcare Improvement, Boston, 1997.

19. Guidelines on Dystocia. Society of Obstetricians and Gynaecologists of Canada, 1995.

20. McGrath, Susan K. PhD, and John H. Kennell, MD. “A Randomized Controlled Trial of Continuous Labor Support for Middle-Class Couples: Effect on Cesarean Delivery Rates” BIRTH 35:2 June 2008.

21. Kozhimannil, Katy B., PhD, MPA; et al. “Potential Benefits of Increased Access
to Doula Support During Childbirth.” Am J Manag Care. 2014;20(6):e340-e352. http://www.ajmc.com/publications/issue/2014/2014-vol20-n8/potential-benefits-of-increased-access-to-doula-support-during-childbirth/