Continuous labor support by a doula

INTRODUCTION — Almost all pregnant persons desire a nurturing, supportive companion throughout labor to help them cope with the challenges of giving birth, including pain, fear, anxiety, fatigue, and uncertainty [1-4]. A doula (from the Greek word for a female caregiver) can fulfill these needs, and the continuous labor support that the doula provides can improve labor and birth outcomes [5]. Indeed, meta-analyses have concluded that continuous support during childbirth is an essential aspect of childbirth [6] and has clinically meaningful benefits for pregnant people and infants with no known harm [7].

This topic will focus on the role and impact of doulas during childbirth. Other aspects of labor and childbirth preparation are reviewed separately. (See "Preparation for childbirth".)

WHAT IS A DOULA? — A doula is an individual who has undergone childbirth training and provides physical, emotional, and informational support to pregnant persons and their families before, during, and after they give birth [8-11]. Almost all doulas are female. Doulas are sometimes described by the activity for which they are providing support, such as birth doula, prenatal doula, breastfeeding doula, postpartum doula, and abortion doula.

TRAINING AND ACCREDITATION — Several organizations provide training and accreditation for doulas. Program specifics differ, but most require candidates to:

●Complete required reading from a list

●Complete a multiday training program

●Audit a childbirth education class

●Attend several births

●Receive positive evaluations from laboring persons and health care providers

As an example, DONA International requires attendance for at least three births in which labor lasted at least 15 hours and a positive evaluation from all three clients, as part of their accreditation requirement. An increasing number of doula training programs emphasize issues of social justice and equity [12-14].

WHAT DOES A DOULA DO? — Doulas provide support for the nonmedical aspects of labor and childbirth. They complement the roles of the clinicians (physicians, midwives, and nurses) caring for the patient. They do not replace medical staff, perform clinical or medical tasks, provide medical advice, or intervene in clinical care. Doulas can totally focus on the specific supportive needs of their patient because they are not responsible for monitoring the maternal/fetal medical condition or for supporting multiple patients with competing needs [15,16]. Unfortunately, doulas sometimes report poor acceptance and support from other maternity care providers [11].

The support a doula provides includes [11,17,18]:

●Developing a trusting relationship with the pregnant person and their family so they feel more secure with the birth process.

●Attending to their physical comfort by providing assistance with positioning, breathing, visualization, bathing, grooming, and nonpharmacologic techniques for managing labor pain.

●Listening to their concerns and providing emotional support (eg, praise, reassurance, encouragement).

●Providing information to help them gain a better understanding of medical terms, the labor process, medical procedures, possible complications of labor or birth, and options for coping with pain and uncertainty.

●Affirming birth choices in a nonjudgmental manner and thus promoting autonomy and self-confidence.

●Advocating for their preferences, when appropriate.

●Facilitating communication between them and the clinical care team and hospital staff to assist in making informed decisions and to ensure that their perspective is being heard.

●Offering culturally centered support and serving as a cultural liaison between them and the clinical care team and hospital staff [19-21].

●Protecting the birth environment from unnecessary and unwanted intrusions, such as uninvited visitors.

BENEFITS OF HAVING A DOULA

●Doulas generally provide continuity of care with an individual that the pregnant person already knows, which may not be possible with support staff or members of the clinical care team who work shifts.

●Doulas focus on patient factors that have been associated with a positive childbirth experience [22]:

•Having good-quality, kind, nurturing, and respectful care

•Having choices and control

•Being informed

•Participating in decision making

These factors may be as important to patient satisfaction as the effects of pain, pain-relief measures, obstetric interventions, labor characteristics, demographics, birth environment, and childbirth preparation [22].

●A nurturing, supportive companion during labor has obvious psychological benefits, and almost all pregnant persons feel that frequent or continuous support during labor helps them cope with its challenges [1-4]. Pregnant persons who had a doula during labor consistently report that the doula had positive effects on their ability to cope with their childbirth and postpartum experiences and enhanced their sense of self-worth and achievement [2-4,23,24].

●Although partners and other individuals (eg, family members, friends) may also be supportive during labor, doulas are professionally trained to provide support and often stay physically closer to the laboring patient, touch them more frequently, talk to them more often, and do not leave them [25]. In at least one study where doulas and partners were both present, one-half of the pregnant persons felt that the doula was more helpful than the partner [2]. It has also been observed that, when a doula is attending the birth, partners offer more physical comfort measures, such as massage and hand holding [26].

●The presence of a doula may allow partners to better focus on their own personal experience of their child's birth since the doula is the primary support of the birthing parent.

●Access to culturally appropriate doula care may facilitate higher rates of breastfeeding initiation [27].

●Doula-supported patients may have better maternal-infant interactions [24].

●A 2016 cost-effectiveness analysis of Medicaid recipients in the United States with access to prenatal doula services found that doula support was associated with potential savings of USD $986 per patient [28].

EVIDENCE OF THE EFFECTIVENESS OF CONTINUOUS LABOR SUPPORT — A few small randomized trials of doula versus non-doula care have been performed and reported favorable effects on various aspects of labor, birth, and newborn care [2,24,29-33]. More data are available on continuous labor support, which is an essential component of doula care. Doulas provide continuous one-on-one labor support, in contrast to the usual labor support provided in hospitals that is intermittent and generally provided by one or more individuals.

In a 2017 meta-analysis of randomized trials comparing the effects of continuous one-to-one intrapartum support by trained or untrained individuals versus usual care, the intervention resulted in small but statistically significant improvements in pregnancy outcomes across a variety of health care settings and socioeconomic and ethnic groups and no harms, although the quality of evidence for each outcome was low [15]. These outcomes included:

●Increase in spontaneous vaginal births (73.3 versus 67.9 percent, relative risk [RR] 1.08, 95% CI 1.04-1.12; 21 trials, n = 14,369 participants).

●Reduction in cesarean birth (10.9 versus 14.6 percent, RR 0.75, 95% CI 0.64-0.88; 24 trials, n = 15,347 participants), which decreases costs.

●Reduction in need of analgesia/anesthesia for pain relief (any analgesia/anesthesia 72 versus 75 percent, RR 0.90, 95% CI 0.84-0.96; 15 trials, n = 12,433 participants).

●Reduction in use of epidural anesthesia (66 versus 69 percent, RR 0.93, 95% CI 0.88-0.99; 9 trials, n = 11,444 participants).

●Reduction in vacuum- or forceps-assisted vaginal birth (18 versus 20 percent, RR 0.90, 95% CI 0.85-0.96; 19 trials, n = 14,118 participants).

●Reduction in length of labor (weighted mean difference -0.69 hours, 95% CI -1.04 to -0.34; 13 trials, n = 5429 participants).

●Reduction in low five-minute Apgar scores (RR 0.62, 95% CI 0.46-0.85; 14 trials, n = 12,615 participants) but nonstatistically significant reductions in admission to the special-care nursery or prolonged newborn hospital stay.

●Reduction in negative childbirth experiences (negative rating 12.2 versus 17.7 percent, RR 0.69, 95% CI 0.59-0.80; 11 trials, n = 11,133 participants).

Continuous labor support can be effective when provided by individuals such as trained family members, trained friends [29], or trained members of the hospital staff; however, benefits accrue most consistently when care is provided by an independent doula who has no other responsibilities while supporting the patient. In a randomized trial in 13 North American hospitals including nearly 7000 participants, continuous labor support provided by specially trained labor nurses did not result in clinically important medical benefits compared with usual care [1]. Duration of labor after randomization, neonatal outcomes, and rates of cesarean birth and use of regional anesthesia were similar for both groups.

The absence of significant medical benefits from enhanced nurse support in this trial contributed to the borderline findings of the meta-analysis discussed above, which was dominated by this trial [15]. It is possible that the specially trained nurses were not able to provide as effective emotional and physical support during labor as a doula because they also had to devote time to monitoring the status of other patients and were not present throughout labor and birth. The nurses changed with each shift and attended to their patient only 80 percent of the time, while a doula would remain with the patient continuously throughout labor until birth. In addition, it has been hypothesized that the nurses may have been more likely than doulas to support standard institutional patterns of pharmacologic pain relief adjuvants, confounding possible effects of these agents on the cesarean birth rate. Lastly, this trial included a high proportion of highly educated, White participants who gave birth in hospitals with high rates of routine medical interventions (eg, use of oxytocin, electronic fetal monitoring, and regional anesthesia), supporting the hypothesis that continuous labor support in this population is less likely to influence use of epidural analgesia. In an economically disadvantaged population, pregnant persons accompanied by doulas reduced epidural use by at least 70 percent compared with those without doulas (approximately 7 versus 23 to 55 percent without a doula) [30,34], whereas in more economically advantaged populations, the use of epidural was the same with or without a doula or only slightly decreased (eg, 54 versus 66 percent) [1,2,35].

DOULAS AND CESAREAN BIRTH — Continuous doula support during cesarean birth is a growing practice at many birthing units to enhance patient-centered care in the operating room. For example, doulas trained to support cesarean birth can increase the use of maternal-newborn skin-to-skin contact [36].

FINDING A DOULA

●Private doulas – Most doulas are self-employed. Pregnant persons who choose to hire a private doula meet with them before labor and discuss their general philosophy toward birth and any past experiences. Sample interview questions are listed in the table (table 1).

A private doula can provide antepartum education and support, answer questions, and help develop a birth plan. When the client is in early labor, the doula may go to the client's home and then accompany the client to the hospital, or the doula may meet the laboring patient on the labor unit. Some private doulas offer postpartum services, such as visiting the new mother and newborn to provide information and answer questions, help with household chores, and give breastfeeding advice.

Fees vary in different parts of the United States, depending on the services provided, and may range from USD $600 to $2500. A growing number of states have passed legislation for Medicaid to cover doula services [37,38], and some private payers offer reimbursement. In addition, a growing number of community-based nonprofit organizations offer doula support at low or no cost [39]. Doula care is one of the components of holistic care advocated by the Black Mamas Matter Alliance [40].

●Hospital doulas – Some hospitals have programs that offer a doula to pregnant patients when they are admitted to the labor unit. The doula will stay with them until they give birth. This type of doula is a volunteer or a hospital employee who is on call, familiar with the institution's routines, and has a preexisting rapport with the medical staff. The doula may provide services at no cost, for a nominal fee, or on a fee-for-service basis.

Doula referral organizations — Hospitals and prenatal care providers may be good resources for finding doulas in a community. The following national and international organizations are also good resources. Each organization provides referrals for persons seeking doula services.

●DONA International

https://www.dona.org/

35 East Wacker Drive, Ste. 850

Chicago, IL 60601-2106

(888) 788-3662

(fax) (312) 644-8557

●toLabor

https://tolabor.com/

PO Box 4410

Richmond, VA 23220

(804) 320-0607

●International Childbirth Education Association (ICEA)

https://icea.org/

110 Horizon Drive, Ste. 210

Raleigh, NC 27615

(919) 674-4183

(fax) (919) 459-2075

●Childbirth and Postpartum Professional Association (CAPPA)

https://cappa.net/

PO Box 547

Flowery Branch, GA 30542

(770) 965-9777

(fax) (888) 688-5241

●The Radical Doula blog provides an online list of volunteer doula programs

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Labor".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Managing pain during labor and childbirth (The Basics)")

PATIENT PERSPECTIVE TOPIC — Patient perspectives are provided for selected disorders to help clinicians better understand the patient experience and patient concerns. These narratives may offer insights into patient values and preferences not included in other UpToDate topics. (See "Patient perspective: Managing pain during labor and delivery".)

SUMMARY AND RECOMMENDATIONS

●Definition – A doula is an individual who has undergone childbirth training and provides physical, emotional, and informational support to pregnant persons and their family before, during, and after they give birth. Continuous one-on-one labor support is an essential component of doula care. (See 'What is a doula?' above.)

●Role of the doula – A doula provides comfort, emotional and physical support, information, and advocacy for laboring patients. The doula does not replace medical staff, perform clinical or medical tasks, or intervene in clinical care but can facilitate communication and help the patient gain a better understanding of the labor process, medical procedures, options for coping with pain and uncertainty, and possible complications of labor or birth. (See 'What does a doula do?' above.)

●Effects on the childbirth experience – A doula can improve the childbirth experience for both the laboring patient and partner (see 'Benefits of having a doula' above). In addition, a meta-analysis of randomized trials that compared continuous one-on-one labor support with usual care reported the following improvements in pregnancy outcome and no harms (see 'Evidence of the effectiveness of continuous labor support' above):

•Reduction in cesarean birth

•Reduction in need of medication for pain relief

•Reduction in use of regional analgesia

•Reduction in length of labor

•Increase in spontaneous vaginal births

•Reduction in negative childbirth experiences

•Reduction in rate of low five-minute Apgar scores

●Finding a doula and cost – Hospitals, prenatal care providers, and national organizations are resources for finding doulas in a community. Many doulas are self-employed. Fees vary in different parts of the United States, depending on the services provided, and may range from USD $600 to $2500. A growing number of states have passed legislation for Medicaid to cover doulas, and some private payers offer reimbursement. In addition, a growing number of community-based nonprofit organizations offer doula support at low or no cost. (See 'Finding a doula' above.)