Medical literature on doulas

Here is a sample of what the medical literature says about doulas : Over 16 studies have been carried out around the world, demonstrating the many benefits of hiring a doula. Here is the latest review and a few others:

Continuous support for women during childbirth (Cochrane Review) Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub2.

Main results
Sixteen trials involving 13,391 women met inclusion criteria and provided usable outcome data. Primary comparison: women who had continuous intrapartum support were likely to have a slightly shorter labour, were more likely to have a spontaneous vaginal birth and less likely to have intrapartum analgesia or to report dissatisfaction with their childbirth experiences. Subgroup analyses: 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.

Authors' conclusions
All women should have support throughout labour and birth.

Side by side — a survey of doula care in the UK in 2008 Goedkoop V. MIDIRS Midwifery Digest, vol 19, no 2, June 2009, pp 217-218)

(…)We conducted a survey of doulas working in the UK during 2008 to 4establish if the results seen in all the various medical studies could be replicated on a more local level, as well as help to raise awareness of the work of Doulas in the UK alongside NHS care.
The survey requested a range of information that included the numbers of births attended, parity, place of birth, use of analgesia, mode of delivery and previous history of caesarean section (CS).

Results
The questionnaire was sent to 450 birth and postnatal doulas and 165 were returned. As some doulas were not active at that time, this affected the number of questionnaires returned. From the 144 birth doula responses, a total of 735 births were recorded in the survey and all the births took place in 2008.
Just under half of the births attended were for primiparous women (350/48%). For 78 (11%) of the women, the doula was her sole birth partner. Twelve women (2%) gave birth to twins. Doulas reported that of all the births they supported, 329 (45%) were completely drug and intervention free (no induction, medicated pain relief, augmentation and instrumental deliveries).
Other notable results were the low number of caesarean sections — this was 112 (15%) which compared to 24.3% in the most recently available NHS maternity statistics (The Information Centre 2008). Women who chose a doula also had a lower rate of epidurals at 148 (20%) compared to what is described as around one third in the NHS statistics, fewer episiotomies, 80 (11%) compared to 13%, and the number of inductions was halved with 76 (10%) of women with a doula being induced versus 20% from the NHS statistics. (…)
We extended the survey to postnatal doulas (who support women once at home and for the first few weeks) and the 114 postnatal doulas who took part in the survey told us that 248 out of 282 women (88%) were still breastfeeding at six weeks and that 161 out of 239 women (67%) were still breastfeeding at six months. (…) Women and their partners who chose a doula had a much lower chance of caesarean section, use of epidural and induction. These women had a greater opportunity to have less medicalised labours, at home and/or in a birthing pool. The higher levels of breastfeeding also demonstrate that the one-to-one continuous support these families are getting helps them achieve this.
The role of the doula as a constant and informed support for both labour and in the early postnatal days gets ever more convincing in the current clinical setting. The shortage of midwives, alongside a greater acknowledgement that there is a need to recapture birth as a event associated with normality rather than an obstetric condition, leaves a gap in the support and philosophical context of what care should be available to the woman with a healthy pregnancy. (...)Where the presence of the doula contributes to higher levels of natural births (low interventions) and breastfeeding rates, these should all be seen as a positive for the NHS where it promotes healthier lifestyles, reduced use of costly resources and more effective use of existing ones.

The obstetrical and postpartum benefits of continuous support during childbirth. Scott KD, Klaus PH, Klaus MH. J Womens Health Gend Based Med 1999 Dec;8(10):1257-64 Division of Public Health, County of Sonoma Department of Health Services, Santa Rosa, California 95404, USA.
The purpose of this article is to review the evidence regarding the effectiveness of continuous support provided by a trained laywoman (doula) during childbirth on obstetrical and postpartum outcomes. Twelve individual randomized trials have compared obstetrical and postpartum outcomes between doula-supported women and women who did not receive doula support during childbirth. Three meta-analyses, which used different approaches, have been performed on the results of the clinical trials. Emotional and physical support significantly shortens labor and decreases the need for cesarean deliveries, forceps and vacuum extraction, oxytocin augmentation, and analgesia. Doula-supported mothers also rate childbirth as less difficult and painful than do women not supported by a doula. Labor support by fathers does not appear to produce similar obstetrical benefits. Eight of the 12 trials report early or late psychosocial benefits of doula support. Early benefits include reductions in state anxiety scores, positive feelings about the birth experience, and increased rates of breastfeeding initiation. Later postpartum benefits include decreased symptoms of depression, improved self-esteem, exclusive breastfeeding, and increased sensitivity of the mother to her child's needs. The results of these 12 trials strongly suggest that 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.

Continuous emotional support during labor in a US hospital. A randomized controlled trial. Kennell J, Klaus M, McGrath S, Robertson S, Hinkley C. JAMA 1991 May 1;265(17):2197-201 Department of Pediatrics, Case Western Reserve University, Cleveland, OH.
The continuous presence of a supportive companion (doula) during labor and delivery in two studies in Guatemala shortened labor and reduced the need for cesarean section and other interventions. In a US hospital with modern obstetric practices, 412 healthy nulliparous women in labor were randomly assigned to a supported group (n = 212) that received the continuous support of a doula or an observed group (n = 200) that was monitored by an inconspicuous observer. Two hundred four women were assigned to a control group after delivery. Continuous labor support significantly reduced the rate of cesarean section deliveries (supported group, 8%; observed group, 13%; and control group, 18%) and forceps deliveries. Epidural anesthesia for spontaneous vaginal deliveries varied across the three groups (supported group, 7.8%; observed group, 22.6%; and control group, 55.3%). Oxytocin use, duration of labor, prolonged infant hospitalization, and maternal fever followed a similar pattern. The beneficial effects of labor support underscore the need for a review of current obstetric practices.

The doula: an essential ingredient of childbirth rediscovered. Klaus MH, Kennell JH. University of California at San Francisco, USA. -Acta Paediatr 1997.
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 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.

Benefits of massage therapy and use of a doula during labor and childbirth. Keenan P. Altern Ther Health Med 2000 Jan;6(1):66-74 Potomac Massage Training Institute, USA.
This article reviews the most recent literature on touch support and one-to-one support during labor and childbirth. The positive and negative aspects of the traditional birth attendant are presented. Research in one-to-one care and touch support during labor is examined with respect to husband/partner, nurses, nurse-midwives, and doulas (trained labor attendants). According to recent studies, women supported by doulas or midwives benefit by experiencing shorter labors and lower rates of epidural anesthesia and cesarean section deliveries. Also, a smaller percentage of their newborns experience fetal distress and/or are admitted to neonatal intensive care units. Women whose husbands or partners massage them during labor experience shorter labors. Nursing one-to-one support results in no significant obstetric outcomes. Antenatal perineal massage was found to reduce the rates of tears, cesarean section, and instrumental deliveries. Research in perineal massage during labor has shown no benefit.

Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers' wellbeing in a Mexican public hospital: a randomised clinical trial. Langer A, Campero L, Garcia C, Reynoso S. Br J Obstet Gynaecol 1998 Oct;105(10):1056-63 The Population Council, Regional Office for Latin America and the Caribbean, Colonia Coyoacan, Mexico DF, Mexico.
OBJECT: To evaluate the effects of psychosocial support during labour, delivery and the immediate postpartum period provided by a female companion (doula). DESIGN: The effects of the intervention were assessed by means of a randomised clinical trial. Social support by a doula was provided to women in the intervention group, while women in the control arm received routine care. SETTING: A large social security hospital in Mexico City. PARTICIPANTS: Seven hundred and twenty-four women with a single fetus, no previous vaginal delivery, < 6 cm of cervical dilatation, and no indications for an elective caesarean section were randomly assigned to be accompanied by a doula, or to receive routine care. OUTCOME MEASURES: Breastfeeding practices, duration of labour, medical interventions, mother's emotional conditions, and newborn's health. METHODS: Blinded interviewers obtained data from the clinical records, during encounters with women in the immediate postpartum period, and at their homes 40 days after birth. Relative risks and confidence intervals were estimated for all relevant outcomes. RESULTS: The frequency of exclusive breastfeeding one month after birth was significantly higher in the intervention group (RR 1.64; I-C: 1.01-2.64), as were the behaviours that promote breastfeeding. However, the programme did not achieve a significant effect on full breastfeeding. More women in the intervention group perceived a high degree of control over the delivery experience, and the duration of labour was shorter than in the control group (4.56 hours vs 5.58 hours; RR 1.07 CI (95%) = 1.52 to -0.51). There were no effects either on medical interventions, mothers' anxiety, self-esteem, perception of pain and satisfaction, or in newborns' conditions. CONCLUSIONS: Psychosocial support by doulas had a positive effect on breastfeeding and duration of labour. It had a more limited impact on medical interventions, perhaps because of the strict routine in hospital procedures, the cultural background of the women, the short duration of the intervention, and the profile of the doulas. It is important to include psychosocial support as a component of breastfeeding promotion strategies.

A birth intervention: The therapeutic effects of Doula support versus Lamaze preparation on first-time mothers' working models of caregiving G. Manning-Orenstein Altern Ther Health Med 1998 Jul;4(4):73-81
CONTEXT: A working model of caregiving has been defined as an internalized schema of caregiving that guides a mother's behavior with her infant. This schema is strongly influenced by the mother's first attachment relationship with her own mother, which frequently operates outside her conscious awareness. OBJECTIVE: To examine doula support at birth as an intervention that might correct distortions of a mother's unconscious schema of caregiving, promoting more secure caregiving following childbirth. DESIGN: The effects of doula support versus Lamaze birth preparation on the working models of caregiving of 35 first-time pregnant mothers were compared. INTERVENTIONS: An interview was used to assess the mothers' working models in the third trimester of pregnancy and again 4 months after the mothers gave birth. Mood state and self-esteem were measured at these times. A post hoc analysis was performed on the mothers' birth experiences, the quality of their postpartum support, and their evaluations of their infants' temperaments. RESULTS: The prebirth to postbirth rating analysis of the interviews revealed that the mothers in the doula group were significantly less rejecting and helpless in their working models of caregiving than were the mothers in the Lamaze group. The mothers in the doula group also showed greater security than did mothers in the Lamaze group, a difference that approached but did not reach significance. In addition, the women in the doula group were less emotionally distressed and had higher self-esteem than did the women in the Lamaze group, and the women in the doula group rated their infants as significantly less fussy than the mothers in the Lamaze group rated their infants. CONCLUSIONS: When viewed in the context of working models of caregiving, mothers who used a doula were significantly less rejecting and helpless, and approached significantly higher scores on the secure scale, than did mothers who used Lamaze birth preparation. Mothers rated as secure showed significantly less mood disturbance and higher prebirth and postbirth self-esteem than did mothers rated as insecure, providing construct validity for the caregiving interviews.