In 2012, Hodnett et al. published an updated Cochrane review on the use of continuous support for women during childbirth. They pooled the results of 22 trials that included more than 15,000 women. These women were randomized to either receive continuous, one-on-one support during labour or “usual care.” The quality of the studies was good.
Continuous support was provided either by a member of the hospital staff, such as a midwife or nurse (9 studies), women who were not part of the woman’s social network and not part of hospital staff (doula 5 studies; childbirth educators 1 study, retired nurses 1 study), or a companion of the woman’s social network such as a female relative or the woman’s partner (6 studies). In 11 studies, the husband/partner was not allowed to be present at birth, and so continuous support was compared to no support at all. In all the other studies, the husband or partner was allowed to be present in addition to the person providing continuous labor support.
Overall, women who received continuous support were more likely to have spontaneous vaginal births and less likely to have any pain medication, epidurals, negative feelings about childbirth, vacuum or forceps-assisted births, and C-sections. In addition, their labours were shorter by about 40 minutes and their babies were less likely to have low Apgar scores at birth.
What does this mean?
It means that if you have continuous labour support (that is, someone who never leaves your side), you are statistically more likely to have better outcomes and your baby is more likely to have better outcomes!
How did doulas compare to the other types of continuous support?
The researchers also looked to see if the type of support made a difference. They wanted to know—does it matter who you choose for your continuous support? Does it matter if you choose a midwife, doula, or partner for your continuous support? They were able to look at this question for 6 outcomes: use of any pain medication, use of Pitocin during labour, spontaneous vaginal birth, C-section, admission to special care nursery after birth, and negative ratings of birth experience.
For most of these outcomes,* the best results occurred when woman had continuous labor support from a doula– someone who was NOT a staff member at the hospital and who was NOT part of the woman’s social network. When continuous labour support was provided by a doula, women experienced a:
- 31% decrease in the use of Pitocin*
- 28% decrease in the risk of C-section*
- 12% increase in the likelihood of a spontaneous vaginal birth*
- 9% decrease in the use of any medications for pain relief
- 14% decrease in the risk of newborns being admitted to a special care nursery
- 34% decrease in the risk of being dissatisfied with the birth experience*
For four of these outcomes,* results with a doula were better than all the other types of continuous support that were studied. For the other outcomes, there was no difference between types of continuous support.
Why are doulas so effective?
A doula can act as a buffer in a harsh environment.
There are 3 main reasons why we think doulas are so effective. The first reason is the “harsh environment” theory. In most developed countries, ever since birth moved out of the home and into the hospital, women have been giving birth in conditions that can often be described as harsh. In the hospital, labouring women are frequently submitted to institutional routines, high intervention rates, personnel who are strangers, lack of privacy, bright lighting, and needles. Most of us would have a hard time dealing with these conditions when we’re feeling our best. But women in labour to deal with these harsh conditions when they are in their most vulnerable state. These harsh conditions may slow down a woman’s labour and decrease the woman’s self-confidence. It is thought that a doula “buffers” this harsh environment by providing continuous support and companionship which promotes the mother’s self-esteem (Hofmeyr, Nikodem et al. 1991).
The third reason that doulas are effective is because doulas are a form of pain relief (Hofmeyr, 1991). With continuous support, women are less likely to request epidurals or pain medication (Hodnett, 2011). Why are women with doulas less likely to request pain medications? Well, women are less likely to request pain medications when they have a doula because they just don’t need an epidural as much! Women who have a doula are statistically more likely to feel less pain when a doula is present. Furthermore, by avoiding epidural anesthesia, women may avoid many medical interventions that often go along with an epidural, including Pitocin augmentation and continuous electronic fetal monitoring (Caton, Corry et al. 2002).