Research
Findings of Hodnett's et al meta-analysis of 15 trials from N. America, Europe and Africa. Women cared for during labour by a doula, compared to those receiving usual care were:
- 26% less likely to give birth by caesarean section.
- 41% less likely to give birth with a vacuum extractor or forceps.
- 28% less likely to use any analgesia or anaesthesia.
- 33% less likely to be dissatisfied or negatively rate their birth experience.
The following is a list of research papers that support the work of doulas (I have included the official summaries):
Berry, LM. (1988) "Realistic expectations of the labor coach"
Journal of Obstetric, Gynecologic and Neonatal Nursing. Sept/Oct: 354-55.
This descriptive, retrospective survey (part of a larger study) employed a questionnaire to determine the behaviors of 40 expectant fathers to the stress generated by their spouses' labors and deliveries. Results indicated that the experience was stressful for all the expectant fathers, and expectant fathers only coached their spouses with their breathing exercises at labor's peak. Fathers spent more time trying to hide their feelings and worrying about their usefulness. These findings have significance for the prenatal education of couples, the education of health professionals, and the practice of labor and delivery nursing.
Hofmeyr, GJ., Nikodem, VC., Wolman, WL., Chalmers BE., Kramer T. (1991) "Companionship to modify the clinical birth environment: effects on progress and perceptions of labour, and breastfeeding." British Journal of Obstetrics and Gynaecology 98:756-764.
OBJECTIVE--To measure the effects of supportive companionship on labour and various aspects of adaptation to parenthood, and thus by inference the adverse effects of a clinically orientated labour environment on these processes.
DESIGN--Randomized controlled trial.
SETTING--A community hospital familiar to most of the participants, with a conventional, clinically-orientated labour ward.
SUBJECTS--Nulliparous women in uncomplicated labour.
INTERVENTION--Supportive companionship from volunteers from the community with no medical nor nursing experience, concentrating on comfort, reassurance and praise.
MAIN OUTCOME MEASURES--Duration of labour, use of analgesia, perceptions of labour and breastfeeding success.
RESULTS--Companionship had no measurable effect on the progress of labour. Diastolic blood pressure and use of analgesia were modestly but significantly reduced. The support group were more likely to report that they felt that they had coped well during labour (60 vs 24%, P less than 0.00001). Their mean labour pain scores (26.0 vs 44.2, P less than 0.00001) and state anxiety scores (28.2 vs 37.8, P less than 0.00001) were lower than those of the control group. Compared with the control group (n = 75), at 6 weeks women in the support group (n = 74) were more likely to be breastfeeding exclusively (51 vs 29%, P less than 0.01); and to be feeding at flexible intervals (81 vs 47%, P less than 0.0001).
CONCLUSIONS--Labour in a clinical environment may undermine women's feelings of competence, perceptions of labour, confidence in adapting to parenthood and initiation of successful breastfeeding. These effects may be reduced by the provision of additional companionship during labour aimed to promote self-esteem.
Kennel, J., Klaus, MH., McGrath, S., Robertson, S., Hinkley, C. (1991) "Continuous emotional support during labor in a US hospital." Journal of American Medical Association 265(17): 2197-2201.
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.
Klaus, MH., Kennell, JL., Robertson, SS., Sosa, R. (1986) "Effects of social support during parturition on maternal and infant morbidity." British Medical Journal 293(6547): 585-7.
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.
Langer A., Campero L., Garcia C., Reynoso S. (1998) "Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers' wellbeing in a Mexican public hospital: a randomised clinical trial." British Journal of Obstetrics and Gynaecology October 1998, 105(10):1056-63.
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: 1.012.64), 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.
Manning-Orenstein G. (1998) "A birth intervention: the therapeutic effects of Doula support versus Lamaze preparation on first-time mothers' working models of caregiving." Alternative Therapies in Health and Medicine July 1998, 4(4):73-81.
Context . A working model of caregiving has been defined as an internalized schema of caregiving that guides a mothers behavior with her infant. This schema is strongly influenced by the mothers 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 mothers unconscious schema of caregiving, promoting more secure caregiving ollowing 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.
Nolan, M. (1995) "Supporting women in labour: the doula's role." Modern Midwife, March 1995 5(3):12-5.
A doula is a woman without medical experience who guides and assists a new mother in childbirth and babycare tasks. The doula's role is to hold the woman, breathe with her, smile at her and provide encouragement and reassurance. Doula support for the labouring woman may reduce catecholamine levels, thus shortening the duration of labour. Doula support can increase self-esteem in the labouring woman and facilitate her transition to motherhood. Rates of oxytocin augmentation, epidural anaesthesia and caesarean section can be reduced by doula support. Fathers may find it hard to provide doula-type support during labor because of their own emotional involvement in the birth. The introduction of doulas into labour wards could lead to reduced costs for maternity services.
Perez PG; Herrick LM. (1998) "Doulas: exploring their roles with parents, hospitals, & nurses." Awhonn Lifelines, April 1998, 2(2):54-5.
Giant strides in improving outcomes for mothers and babies and preventing unnecessary cesareans are being made, not by machines and technology, but by human touch. It's this touch that's helping women cope with labor without having to resort to drugs and surgery, and it's coming from a new kind of labor and birthing assistant, a doula.
Schuiling KD., Sampselle CM. (1999) "Comfort in labor and midwifery art." Image - the Journal of Nursing Scholarship, 1999, 31(1):77-81.
Purpose: To examine the phenomenon of comfort in the context of childbirth. Enhancement of comfort for laboring women is a valued outcome of nursing and midwifery care. Interventions that increase comfort during labor support a woman's effort to participate more fully in the birth thereby keeping her more aware of her body, emotions, and experience.
Organizing construct: The concept of comfort is analyzed and defined in the context of laboring women. Comfort studied from a feminist perspective is suggested.
Sources: A literature review of nursing, midwifery, and medical texts from the 1920s to 1998 provides information about labor, pain in labor, and goals of providers caring for laboring women. Research articles focusing on comfort are identified as they relate to the concept of comfort in labor. Writings of contemporary feminist authors provided the ideas for designing the study of comfort from a feminist perspective.
Methods: To develop a theory of comfort during labor, early nursing and midwifery texts were searched to identify goals of care. The meaning of comfort was analyzed from the early 1920s to the present by concept analysis. Validation of findings was sought from publications on comfort research.
Findings: Comfort can exist in spite of great pain and nurses and midwives may be able to assist laboring women to achieve a level of comfort during labor. Intervening to promote the comfort of laboring women can empower these women during birthing. Conclusions: For clinicians caring for birthing women, particularly midwives, promotion of comfort is a high priority. Increasing comfort can redefine the meaning of pain in childbirth. Increasing comfort may create a decreased need for medical interventions and lower costs.
Sosa, R., Kennel, J., Robertson, S., Urrutia, J. (1980) "The effect of a supportive companion on perinatal problems, length of labor, and mother-infant interaction." The New England Journal of Medicine. 303(11):597-600.
We studied the effects of a supportive lay woman ("doula") on the length of labor and on mother-infant interaction after delivery in healthy Guatemalan primigravid women. Initial assignment of mothers to the experimental (doula) or control group was random, but controls showed a higher rate (P less than 0.001) of subsequent perinatal problems (e.g. cesarean section and meconium staining). It was necessary to admit 103 mothers to the control group and 33 to the experimental group to obtain 20 in each group with uncomplicated deliveries. In the final sample, the length of time from admission to delivery was shorter in the experimental group (8.8 vs. 19.3 hours, P less than 0.001). Mothers who had a doula present during labor were awake more after delivery (P less than 0.02) and stroked (P less than 0.001), smiled at (P less than 0.009), and talked to (P less than 0.002) their babies more than the control mothers. These observations suggest that there may be major perinatal benefits of constant human support during labor.
Zhang J., Bernasko JW., Leybovich E., Fahs M., Hatch MC. (1996) "Continuous labor support from labor attendant for primiparous women: a meta-analysis." Obstetrics and Gynecology, October 1996, 88(4 Pt 2):739-44.
OBJECTIVE: To evaluate the available literature on the effects of continuous labor support among primiparous women. DATA SOURCES: We did a Medline search using the keywords "labor support," "doula," and "monitrice." Papers published in English from 1965 to May 1995 were eligible for this review. We also cross-checked all the references in the selected reports.
METHODS OF STUDY SELECTION: We identified seven randomized clinical trials published during that period; four of these were eligible for our meta-analysis.
DATA EXTRACTION AND SYNTHESIS: Meta-analysis of four studies conducted among young, low-income, primiparous women who gave birth on a busy labor floor in the absence of a companion suggested that continuous labor support by a labor attendant shortens the duration of labor by 2.8 hours (95% confidence interval [CI] 2.2-3.4), doubles spontaneous vaginal birth (relative risk [RR] 2.01, 95% CI 1.5-2.7) and halves the frequency of oxytocin use (RR 0.44, 95% CI 0.4-0.7), forceps use (RR 0.46, 95% CI 0.3-0.7), and cesarean delivery rate (RR 0.54, 95% CI 0.4-0.7). Women with labor support also reported higher satisfaction and a better postpartum course.
CONCLUSION: Labor support may have important positive effects on obstetric outcomes among young, disadvantaged women. Further studies on benefit relative to cost are needed before a broad-scale program is advocated.
Susan K. McGrath, PhD , John H. Kennell, MD. "A Randomized Controlled Trial of Continuous Labor Support for Middle-Class Couples: Effect on Cesarean Delivery Rates." Birth, June 2008, 35(2): 92-97.
Background: Previous randomized controlled studies in several different settings demonstrated the positive effects of continuous labor support by an experienced woman (doula) for low-income women laboring without the support of family members. The objective of this randomized controlled trial was to examine the perinatal effects of doula support for nulliparous middle-income women accompanied by a male partner during labor and delivery.
Methods: Nulliparous women in the third trimester of an uncomplicated pregnancy were enrolled at childbirth education classes in Cleveland, Ohio, from 1988 through 1992. Of the 686 prenatal women recruited, 420 met enrollment criteria and completed the intervention. For the 224 women randomly assigned to the experimental group, a doula arrived shortly after hospital admission and remained throughout labor and delivery. Doula support included close physical proximity, touch, and eye contact with the laboring woman, and teaching, reassurance, and encouragement of the woman and her male partner.
Results: The doula group had a significantly lower cesarean delivery rate than the control group (13.4% vs 25.0%, p = 0.002), and fewer women in the doula group received epidural analgesia (64.7% vs 76.0%, p = 0.008). Among women with induced labor, those supported by a doula had a lower rate of cesarean delivery than those in the control group (12.5% vs 58.8%, p = 0.007). On questionnaires the day after delivery, 100 percent of couples with doula support rated their experience with the doula positively.
Conclusions: 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. Women and their male partners were unequivocal in their positive opinions about laboring with the support of a doula.
