New clinical evidence reveals that science is still catching up on where doula support truly makes a difference and its impact during birth and beyond.
Research: Doula care and health outcomes. Image credit: Pixel-Shot/Shutterstock.com
Doula care is a non-medical approach aimed at enhancing the care of mothers during and after childbirth. Systematic reviews in journals JAMA network open Despite substantial heterogeneity between studies, we demonstrate that doula care can help improve equity of care and maternal and child health outcomes in the perinatal period.
Doula support emerges as a response to the care gap
Inequalities in maternal and child health continue, with higher rates of cesarean section, preterm birth, and critical illness among marginalized groups, especially American Indians, Alaska Natives, and Black Americans. These disparities are driven, in part, by structural and social determinants of health, such as systemic inequalities and racism. Doula care may help remediate these disparities, but there is a lack of systematic evidence, which motivates the current review.
Doulas are community-based professionals who work in all settings: home, community, and hospital. They are trained to provide physical, emotional and educational support during the perinatal period. Doulas educate mothers about pregnancy, childbirth, and postpartum care, supporting their comfort, confidence, and emotional well-being.
Doula care is endorsed by the American College of Obstetricians and Gynecologists. Combined with the expansion of Medicaid coverage, this has contributed to increased interest in and access to doula care.
Doula care may also be provided for other reproductive health conditions, such as fertility support, and may be available at home, in the community, or in the hospital.
Global trial reveals wide variation in doula care
This paper featured 22 papers reporting 21 different studies. Most were randomized controlled trials involving various interventions, often compared to standard treatments that were not always clearly defined.
More than half of the studies were conducted in the United States, and more than 80% used a single doula, whereas about 20% used a team-based approach. Most studies focused on the birth period. Five studies investigated the period from prenatal to postnatal.
Some studies focused on low-income or nulliparous populations, while others did not have a specific target group. More than 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 planned prenatal or postnatal visits. They evaluated doula functions such as coaching, repositioning, advocacy, emotional support, and education about childbirth, infant care, and self-care. Intervention intensity, duration, and doula training approaches varied widely, contributing to the heterogeneity between studies.
Some studies have compared doula care with alternative support interventions such as trained lay companions, family support workers, and music therapy. Several studies have evaluated birth outcomes. Few studies have examined postnatal health, abortion, or broader reproductive health outcomes.
Doula care is associated with improved several outcomes
Epidural use was lower in doula care, but oxytocin use had mixed results. Results regarding birth outcomes were mixed, with some studies showing benefits and others reporting no significant differences.
The strongest associations have been shown between doula care and reduced maternal anxiety and increased rates of breastfeeding initiation, although recent evidence suggests improved postpartum follow-up.
Evidence for other outcomes was mixed. For example, several studies have reported that doula care reduces postpartum depression. However, other studies have reported higher rates of depression. The authors of that study suggest the possibility of reverse causation. Additionally, while depression develops over time, anxiety most often occurs during labor, when doula care is most intensive.
Of the eight studies that evaluated doula care practices, nearly all reported high patient satisfaction.
Comparing the results of clinical trials and other studies
Observational studies have shown that doula care is associated with a reduced risk of cesarean delivery, lower rates of preterm birth, and fewer inductions of labor. Several systematic reviews have demonstrated its benefits, as has the 2017 Cochrane meta-analysis, although the latter has wide confidence intervals for its results and cites low-quality evidence.
These findings have not been clearly confirmed in clinical trials. This may be due to some methodological limitations.
These include poor study design, variation in doula care delivery methods, and limited reporting of intervention fidelity. Follow-up periods were also often short and limited to the immediate postpartum period.
Additional challenges include potential crossover between study groups, variable study designs, poor representation of marginalized populations, and uncertainty in protocol adherence.
Some high-need groups remain underrepresented. These include mothers in prison and mothers of children with complex medical conditions, the people who could benefit most from doula care.
Underserved populations, such as individuals experiencing intimate partner violence, are also poorly represented in the evidence base despite potentially high need.
Doula care shows promise in selected maternal outcomes
The study’s findings suggest that “doula care may improve perinatal anxiety, health care utilization, and breastfeeding initiation,” but there is mixed evidence about other outcomes.
Further rigorous testing is needed to explore all aspects of perinatal care, targeting areas where doula care can complement pharmacological management. These should be longitudinal studies with diverse and unbiased samples.
Furthermore, the implementation of doula care should be analyzed, including the barriers and factors that facilitate such care. This evidence is key to integrating doula care into existing health care systems.
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