The Evidence on: Doulas

If you haven't checked out Evidence Based Birth  yet, definitely put it on your list! This is a fantastic website dedicated to breaking down the studies and facts on common pregnancy related issues. Although it is based in the US, very relevant to expecting Canadian couples as well!

What is a doula?

According to Dr. Christine Morton, author of the book Birth Ambassadors, a birth doula is a companion who supports a birthing person during labor and birth. Birth doulas are trained to provide continuous, one-on-one care, as well as information, physical support, and emotional support to birthing persons and their partners.

Photo by Daiga Ellaby on Unsplash

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What do doulas do?

Doulas nurture and support the birthing person throughout labor and birth. Their essential role is to provide continuous labor support to the mother, no matter what decisions the mother makes or how she gives birth. Labor support is defined as the therapeutic presence of another person, in which human-to-human interaction with caring behaviors is practiced (Jordan, 2013).
Importantly, the doula’s role and agenda are tied solely to the birthing person’s agenda. This is also known as primacy of interest. In other words, a doula’s primary responsibility is to the birthing person—not to a hospital administrator, nurse, midwife, or doctor.
A doula can provide labor support via the four pillars of labor support. In the textbook Best Practices in Midwifery, the author describes three pillars of labor support as emotional support, physical support, and advocacy. In the book Optimal Care in Childbirth, informational support is also listed as a pillar of support.

What is NOT included in doula support?

Doulas are not medical professionals, and the following tasks are not performed by doulas:

• 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 make decisions for the client (medical or otherwise)
• They do not pressure the birthing person into certain choices just because that’s what they prefer
• They do not take over the role of the partner
• They do not catch the baby
• They do not change shifts (although some doulas may call in their back-up after 12-24 hours)

What is the evidence on doulas?

In 2017, Bohren et al. published an updated Cochrane review on the use of continuous support for women during childbirth. They combined the results of 26 trials that included more than 15,000 people. The birthing people in these studies were randomized to either receive continuous, one-on-one support during labor or “usual care.” The Cochrane reviewers stated that the overall quality of the studies was good.
Continuous support was provided either by a member of the hospital staff, such as a midwife or nurse (nine studies), women who were not part of the birthing person’s social network and not part of hospital staff (doula, eight studies; childbirth educators, one study, retired nurses, one study), or a companion from the birthing person’s social network such as a female relative or the woman’s partner (seven studies). In 15 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 11 studies, the husband or partner was allowed to be present in addition to the person providing continuous labor support.
Overall, people 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 Cesareans. In addition, their labors were shorter by about 40 minutes and their babies were less likely to have low Apgar scores at birth.  There is a smaller amount of evidence that doula support in labor can lower postpartum depression in mothers. There is no evidence for negative consequences to continuous labor support.
The results of this study mean that if a birthing person has continuous labor support (that is, someone who never leaves their side), both mothers and babies are statistically more likely to have better outcomes!

Photo by Liv Bruce on Unsplash

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 birthing persons choose for continuous support? Does it matter if they choose a midwife, doula, or partner for continuous support? The researchers were able to look at this question for six outcomes: use of any pain medication, use of Pitocin during labor, spontaneous vaginal birth, Cesarean, admission to special care nursery after birth, and negative birth experiences.
For most of these outcomes (designated with asterisks*), the best results occurred when a birthing person had continuous labor support from a doula– someone who was NOT a staff member at the hospital and who was NOT part of their 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 Cesarean*
• 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.

* for full article please visit the Evidence Based Birth website