New clinical evidence reveals where doula support truly makes a difference, and where the science is still catching up on its impact across childbirth and beyond.
Study: Doula Care and Health Outcomes. Image credit: Pixel-Shot/Shutterstock.com
Doula care is a non-medical approach designed to enhance maternal care during and after childbirth. A systematic review in the journal JAMA Network Open demonstrates that despite substantial heterogeneity between studies, doula care may help improve equity in care and maternal and infant health outcomes during the perinatal period.
Doula support emerges as response to care gaps
The state of maternal and infant health remains unequal, with higher rates of cesarean delivery, preterm birth, and severe illness among marginalized groups, especially American Indian, Alaska Native, and Black populations. These disparities are driven in part by structural and social determinants of health, including systemic inequities and racism. Doula care could help correct these disparities, but systematic evidence is lacking, motivating the current review.
A doula is a community-based professional who may work across home, community, and hospital settings. They are trained to provide physical, emotional, and educational support in the perinatal period. Doulas educate mothers about pregnancy, labor, and postpartum care, supporting their comfort, confidence, and emotional health.
Doula care is endorsed by the American College of Obstetricians and Gynecologists. Coupled with expanded Medicaid coverage, this has contributed to growing interest in and access to doula care.
Doula care may also be offered for other reproductive health situations, such as fertility support, and may be available in the home, the community, and the hospital.
Global trials reveal wide variation in doula care
The paper covered 22 articles reporting 21 different studies. Most were randomized controlled trials with varied interventions, often compared with standard care that was not always clearly specified.
Over half of the studies took place in the US, with more than 80 % using a single doula compared with about 20 % using a team-based approach. Most studies targeted the intrapartum period. Five studies examined the prenatal through postpartum period.
Some studies focused on low-income or nulliparous populations, while others had no specific target group. Over 70 % were hospital-based, one was community-based, and five included both settings.
Most studies focused on continuous doula care during labor, followed by several organized visits, prenatal or postpartum. They assessed doula functions such as coaching, repositioning, and advocacy, emotional support, and education for labor, infant care, and self-care. The interventions varied widely in their intensity, duration, and doula training approaches, contributing to heterogeneity across studies.
Some studies compared doula care with alternative support interventions such as trained lay companions, family support workers, or music therapy. Several studies evaluated birth outcomes. Few studies examined postpartum health, abortion, or broader reproductive health outcomes.
Doula care is associated with some improved outcomes
Epidural use was lower with doula care, with mixed results on oxytocin use. Results for birth outcomes were mixed, with some studies showing benefits and others reporting no significant differences.
The strongest associations linked doula care with lower maternal anxiety and higher rates of breastfeeding initiation, while recent evidence suggests improved postpartum follow-up.
Evidence for other outcomes was mixed. For instance, a few studies reported lower postpartum depression with doula care. However, another study reported higher rates of depression. The authors of that study suggest possible reverse causation. In addition, depression develops over time, but anxiety occurs mostly intrapartum, when the most intensive doula care is available.
Of eight studies assessing the implementation of doula care, almost all reported high patient satisfaction.
Contrast between findings from clinical trials and other studies
Multiple observational studies have shown that doula care is associated with reduced cesarean delivery risk, lower rates of preterm birth, and fewer labor inductions. Several systematic reviews demonstrated its benefits, as did a 2017 Cochrane meta-analysis, though the latter cited low-quality evidence with wide confidence intervals for the outcomes.
Clinical trials have not definitively confirmed these findings. This may be due to several methodological limitations.
These include underpowered study designs, variability in how doula care was delivered, and limited reporting of intervention fidelity. Follow-up periods were also often short and restricted to the immediate postpartum timeframe.
Additional challenges include potential crossover between study groups, variable study designs, poor representation of marginalized populations, and uncertain adherence to protocols.
Some high-need groups remain underrepresented. These include mothers in jail or those with children who have complex illnesses – populations that may benefit most from doula care.
Other underserved populations, such as individuals experiencing intimate partner violence, were also largely absent from the evidence base despite potentially high need.
Doula care shows promise for selected maternal outcomes
The findings suggest that “doula care may improve perinatal anxiety, health care utilization, and breastfeeding initiation”, with mixed evidence for other outcomes.
Further rigorous trials are needed to examine all facets of perinatal care to target areas where doula care could complement pharmacological management. These should be long-term studies with diverse and equitable sample representation.
In addition, they should analyze the implementation of doula care, including barriers and factors that promote such care. This evidence is key to integrating doula care into existing healthcare systems.