Evidence on Doulas

What is a doula?

 A doula is a special companion who supports you during pregnancy, labor, and birth (Morton & Clift 2014). Doulas are trained to provide continuous, one-on-one care, physical support, and emotional support during labor. They may also provide information and support to families before or during birth, and into the postpartum period. There are many different types of doulas, along with many different types of training, certifications, traditional practices, and perspectives on doula care.

In this Signature Article, we provide families with evidence they can use when deciding whether and how to work with a doula. Making the evidence on doula care accessible can also educate communities, show the value of doulas to hospitals or medical providers, and help people advocate for policies that embrace doulas. Evidence shows that doulas are valued members of the care team who help improve health outcomes for parents and babies.

Types of doulas

In the late 1900s and early 2000s, the “typical” North American birth doula provided two to three prenatal visits, continuous support during labor/birth, and one visit postpartum. However, in recent years, different types of doulas have emerged and grown in popularity, including postpartum doulas, community-based doulas, full spectrum doulas, and end-of-life doulas. For more information about different types of doulas beyond what is included here, you can check out this link.

Community-based doulas are known, trusted, and skilled individuals who are often from the same marginalized communities as their clients. These special doulas are trained to bridge language and cultural barriers and provide culturally grounded, full-spectrum, and intensive support through pre- conception, pregnancy, postpartum, and beyond (Arcara et al. 2023; LaMancuso, Goldman, & Nothnagle 2016; Health Connect One). They hold important roles as patient advocates who offer emotional and informational support. And they prepare, protect, and hold space for birthing people who are more likely to experience interpersonal and systemic racism through their birthing process (Bey et al. 2019).

Community-based doulas often develop close relationships with their clients. They screen for food insecurity, intimate partner violence, and medical risk factors. They connect families with additional support and care and offer wrap-around care for months or even years later. Learn more about community-based doulas in our Signature Article on Anti-Racism in Healthcare and Birth Work.

Postpartum doulas provide sustained support to birthing people following birth. In comparison to birth doulas, who may offer one or two visits in the early postpartum period, postpartum doulas provide support in the first months after birth. They provide families with support and information about feeding, soothing, and caring for a new infant, as well as offer practical support to family members as they transition into new roles as parents and siblings (Campbell-Voytal et al. 2011; Gjerdingen et al. 2013). Some postpartum doulas also provide care to new families by assisting with light household tasks or night duties related to parenting and infant care.

Full-spectrum doulas offer support before, during, and after pregnancy, including providing support during and after an abortion or loss (Lindsey et al. 2023). Full-spectrum doulas are skilled at providing information and emotional support to people during the full spectrum of pregnancy, from pre-conception, to birth, to abortion, to miscarriage or stillbirth, to adoption, to postpartum (BADT 2021).

End-of-life doulas (also known as death doulas) are companions who support a person towards the end of their life and support the client’s friends and family as they witness the dying process (Krawczyk et al. 2023; Rawlings et al. 2019). Like other doulas, end-of-life doulas are not medical professionals; however, they have experience collaborating with members of their client’s medical or hospice team.

Some doulas, known as loss or bereavement doulas, specialize in providing support to childbearing families who experience miscarriage, fatal fetal diagnosis, stillbirth, or infant loss. In EBB Podcast Episode 195 we speak with a full spectrum doula who focuses on pregnancy and infant loss.

How does someone become a birth doula?

Birth doulas are not medical professionals, and there is no single certifying body that regulates all doulas, standardizes their training, or offers an authoritative certification. Note: For practical purposes, for the rest of this article when we use the term ‘doula’ we are referring to doulas who include birth support in their services. Many doulas choose to be trained and/or certified by independent doula training organizations, but formal training and certification is not a requirement for someone to work as a doula, call themselves a doula, or to provide support during labor and childbirth.

The format of doula training varies widely, from a 3-day in-person workshop with no ongoing mentorship, to a 1-year hybrid in-person and online training with mentorship — and everything in between! Full-spectrum or community-based doula programs tend to offer longer trainings as their trainees go on to offer broader services that cover pre-conception, pregnancy, pregnancy loss, birth, postpartum, and parenting.

There are many doula trainers and training organizations, each with their own area of specialty. Some train internationally, while others choose to focus on a particular country or region. Some certifying organizations offer religious trainings to bring faith practices into the birth experience. Other trainings are tailored to doulas and birthing people who share a racial, ethnic, or LGBTQ+ identity and may want to bring in certain cultural practices, a shared understanding about family, or to protect against misunderstandings or microaggressions from other providers during the birth. Each training organization has a different process for potential doulas to complete and may have different requirements before a doula can be certified with their organization. Some doula training organizations do not believe in certification or re-certification because certification is perceived as inappropriate regulatory control over a voluntary cultural and ancestral community practice.

As a result of this varied landscape of doula organizations, doula trainers, philosophies about doula work and doula certifications, it is common for some doulas to be certified by multiple organizations or trained in multiple types of support.

If you are thinking about becoming a doula, you may want to learn about different doula organizations before deciding which one is the best fit. It is important to consider what types of communities or families you wish to serve, what types of training you want to pursue, and what your own approach to birth work will be.

If you are interested in hiring a doula, you may want to ask your potential doula about their training and/or certification organizations, as part of figuring out what type of doula might be the best fit for your needs.

How many people use doulas?

We have very little data on the number of people who use doulas. In a 2012 survey that took place in the U.S., about 6% of birthing people said they used a doula during childbirth (Declercq et al. 2013), up from 3% in a 2006 national survey (Declercq et al. 2007). Of those who did not have a doula but understood what they were, 27% would have liked to have a doula.

In a 2018 survey that took place in California, 9% of birthing people said that they used a doula during childbirth. Rates of having a doula were higher among Latina women (10%), and Black women (15%) (Sakala et al. 2018).

There is limited research on this topic so far, but families may encounter several barriers to having a doula, including:

• The cost of paying a private doula.

• Being ineligible for and unaware of possible free doula programs in your area.

• The time it takes to interview and find a doula you connect with.

• Learning about doulas too late in your pregnancy, or after the birth.

• Being unaware of the many different types of doulas.

• Thinking that partners, midwives, nurses, or friends can offer the same support as doulas.

• Doulas are not allowed at your hospital or birthing location.

• Your birthing location has policies limiting the number of people who can attend your birth (meaning you have to choose between a doula and other family members or friends).

• Beliefs that doulas are “nice to have,” but only for the wealthy or the very disadvantaged. 

What do doulas do?

Doulas nurture and support you during pregnancy, labor, birth, and the postpartum period. They provide continuous support through labor and birth. They bring a non-medical approach that focuses on providing emotional and physical support, sharing information, and helping prepare you and your support system prior to birth. They typically have stronger labor support and relational skills than most medical staff or health care workers.

It’s quite common that the first time you meet the nurses, midwives, and doctors who assist you in birth will be during the labor or birth itself. By contrast, most doulas aim to establish a relationship with you and your birth partner(s) before the birth—and research shows that families feel more secure going into labor with a doula they already know and trust (Banda et al. 2010; Akhavan & Lundgren 2012; Lunda, Minnie, & Benadé 2018). Doulas find that this mutual trust is important for providing effective support in labor (Bohren et al. 2019a).

Also, many families are surprised to find that medical providers do not stay with you for very long during labor—instead, they do brief check-ins, with a focus on carrying out medical tasks. This is quite different from doulas, who usually stay with you from the beginning to the end of labor. We explore the evidence on the benefits of continuous support of doulas in childbirth later in this article.

Some doulas, such as community-based doulas, have expanded roles where they support you throughout your pregnancy. And there are postpartum doulas who provide extended care after the birth for newborn feeding and parenting support.

Many doulas may offer other services or forms of expertise in addition to being a doula. From placenta encapsulation to birth photography to lactation support, many doulas are multi-hyphenated birth workers.

On top of building trust with you, a doula’s essential role is to support you through labor and birth, no matter what decisions you make or how you choose to give birth.

What is labor support?

Labor support is defined as the therapeutic presence (human-to-human interaction with caring behaviors) of another person with you during labor (Jordan2016).

Labor support is typically provided in-person, but sometimes it is provided virtually. During the first years of the COVID-19 pandemic, hospital restrictions meant that some doulas could not accompany their clients into hospitals to provide in-person labor support. Doulas found creative ways to provide virtual labor support, often staying on the phone with birthing people and remaining in contact throughout labor and birth, or by providing postpartum support via video call, or dropping off supplies to new parents (Ochapa et al. 2023; Oparah et al. 2021).

Any person who is on your care team (such as a family member or friend, nurse, student, midwife, and even the occasional physician) can provide labor support. However, doulas are unique in that their entire focus is continuous labor support—they do not have other clinical tasks distracting them from this role. The benefit of continuous labor support is so powerful that researchers have found that providing even brief doula training to friends and family members can improve birthing people’s experiences in childbirth (Nguyen & Heelan-Fancher 2022).

The doula’s role and goals are tied solely to your goals. This is known as primacy of interest. In other words, a doula’s primary responsibility is to the birthing person — not to a hospital administrator who may be thinking about finances, not to a charge nurse who may be worrying about bed availability, not to a partner who may be wrestling with their own anxieties, and not to the midwife or doctor who may be concerned about avoiding rare life-threatening emergencies or protecting their own legal liability.

The four pillars of labor support that a doula can provide include physical support, emotional support, informational support, and advocacy.

Physical Support

“We called our doula and she was at the hospital waiting for us. She was there when I got out of the car, and she and Henry [partner] were holding me through contractions as we made our way into the hospital. I have a very vivid memory of her holding my shoulder and then slowly moving her hand down my arm as my contractions faded. It made me feel more relaxed as the contractions ended and then Henry started doing something similar. It was amazing, at times I didn’t know whether it was her or Henry, but I remember that feeling so, just very caring.” (Hunter 2012)

Feeling physically and emotionally safe during childbirth is important to ensure the best outcomes (Kozhimannil et al. 2016). Physical support is important because it helps you maintain a sense of control, comfort, and confidence, and can provide relief or distraction from pain. Feeling safe can also calm your nerves and allow your body to stay in a relaxed state, so labor will progress at its best. Some examples of physical support that doulas can provide include:

• Soothing touch with massage, counter pressure, acupressure, or other techniques.

• Creating a calm environment, such as dimming lights and arranging curtains.

• Assisting with water therapy (shower, tub).

• Applying warm or cold packs.

• Holding hands and making eye contact.

• Teaching breathing and visualization techniques.

• Guiding you with positions, movement, swaying, pelvic rocking, or using a birth ball or peanut ball.

• Assisting you in walking to and from the bathroom or changing clothes.

• Giving ice chips, food, and drinks.

In low-resource settings or hospitals with staff shortages, doulas can also provide practical support by filling in gaps in care (Khaw et al. 2022). This can include:

• Offering interpretation support or culturally competent care.

• Alerting the staff about unusual symptoms or issues in labor.

• Enhancing continuity of care.

• Changing bedding or maintaining the hygiene and cleanliness of the room.

Community-based doulas may provide even more forms of physical support, such as attending prenatal appointments with you, helping you access nutritious foods, and hosting more frequent in-person or virtual meetings (Arcara et al. 2023; Cidro et al. 2021; Ireland, Montgomery-Andersen, & Geraghty 2019; Wint et al. 2019).

Emotional Support

“With the help of the doula I can trust my ability… she praised me when she heard how I handled my contractions; I could trust that I was on my way into the next stage. It was like an affirmation.” (Berg & Terstad 2006)

Emotional support is a key feature of doula support, helping you feel cared for and centered in your care, and to feel a sense of pride and empowerment after birth. One of the doula’s primary roles is to care for your emotional health and provide a supportive presence that increases the chances of a positive birth experience (Gilliland 2010b).

Doulas may provide the following types of emotional support to you and your birth partner(s):

• Continuous presence.

• Reassurance.

• Encouragement.

• Praise.

• Helping you see yourself or your situation more positively.

• Helping you feel more in control and confident, and aware of your progress.

• Keeping company.

• Showing a caring attitude.

• Calmly describing what you’re experiencing and echoing back the same feelings and intensity, or by mirroring facial expressions.

• Accepting what you and your family want.

• Showing sensitivity to you and your family’s emotions, and helping you work through fears and self-doubt.

• Spiritual support if requested, such as sharing prayers or reading from inspirational texts.

• Debriefing after the birth—listening with empathy.

Informational Support

“[My doulas] gave me another packet of information of things I should be eating… Like preterm labor signs that I should be looking out for… and then things like optional versus protocol in a hospital setting. Like when I’m in labor. Just things that I didn’t even think about or know about.” (Arteaga et al. 2023)

Informational support helps keep you and your birth partner(s) informed about what’s going on with the course of labor, as well as giving you evidence-based information about birth options. All of this can lead to you feeling supported, safe, and experiencing other benefits that come from being at ease in your body. Studies show that doulas often have a basic level of clinical knowledge and can help explain the birthing process and common medical procedures (Bohren et al. 2019b).

Informational support can include:

• Educating you or your family about the birthing process, how long to expect each phase of labor to last, and reasons why medical staff may propose medical interventions.

• Suggesting techniques in labor, such as breathing, relaxation techniques, movement, and positioning (positioning is important both with and without epidurals).

• Helping you find evidence-based information about different options in pregnancy and childbirth.

• Helping explain medical procedures before or while they occur.

• Helping your birth partner(s) understand what’s going on with your labor (for example, interpreting the different sounds you might make).

• Assisting with communication between you and medical providers about medical decisions or procedures – making sure that you and your birth partner(s) understand medical terms and have your questions answered, and that the medical team understands your preferences.

• Helping you and/or your birth partner(s) to speak up and be more engaged, rather than confused or anxious.

• Communicating with additional family members or friends who have come to visit to explain what is happening, how they can support, and when is the best time to enter the birth room (or why it may be best to wait).

Informational support is especially important for birthing families who struggle to understand the language or culture of the hospital, experience neglect or discrimination in health care, or are overwhelmed by the challenges of giving birth.

Advocacy

“There’s so many different ways that you can advocate for somebody, and even with the clients that I work with, I feel like advocacy and what they expect from advocacy looks different depending on who they are, their income level, their race, their gender, their sexual identity. All the different things contribute to advocacy but it looks different depending on the person’s lens.” Sabia Wade, Birth Allowed Radio, episode 37.

Advocacy has become an important conversation within doula care, because birth can be a challenging experience on its own, and because families have experienced trauma, lack of consent, or disagreement with some health care providers about medical decisions. Advocacy is a pillar of support of doula care that can take many forms. Key reasons for this include:

• The term advocacy has several meanings and definitions.

• Doulas differ on how and whether advocacy is part of their role.

• Clients may have different preferences about what kind of advocacy they want from their doula.

• Every doula’s unique approach to advocacy will lead them to different ways of interacting or collaborating with medical staff, as potential solutions or workarounds.

In research on the concept of advocacy in the nurse’s role, Kalaitzidis and Jewell (2015) compiled all the existing definitions of patient advocacy. They found that the most common definitions of advocacy were “pleading the cause of someone” or “speaking on behalf of someone.” Advocacy can also be defined as “supporting an individual or group to gain what they need from the system” or supporting a person in their right to self-determination.

Considering the past definitions of advocacy for nurses, here at Evidence Based Birth® we use the following definition of advocacy in the context of doula care:

Advocacy is defined as supporting the birthing person in their right to make decisions about their own body and baby.

Doulas have diverse perspectives about advocacy

Advocacy has long been considered an essential component of the nurse’s role. However, while some doulas believe that advocacy is a part of their role, others have been specifically trained that advocacy is not part of their role at all.

Foundational to doula practice is the philosophy that a birthing person’s autonomy, or a person’s ability to decide for themselves what they want or do not want during childbirth, is paramount. Doulas assist in this process by facilitating communication, making space and time for reflection, and providing informational or decision-making support (Meadow 2014; Rysdam 2019). However, there is a wide range of individual doulas’ advocacy and communication skills, their desire to advocate or not, and how they support client autonomy. 

For many years, DONA International, one of the first doula training and certification organizations, stated in their standards of practice that advocacy is part of the doula’s role, but only if the doula does not speak on behalf of the client (DONA 2020). However, many doulas have reported to EBB that their doula trainers (from a variety of established doula training organizations) specifically instructed them not to speak at all to health care providers. Furthermore, many doulas do not want to speak for their client, and they are afraid of being mistakenly perceived by health care workers as making medical decisions for their client (Amram et al. 2014).

However, some doulas take a more active role in speaking up to the medical team about a birthing person’s preferences or needs (Cidro et al. 2021; LaMancuso, Goldman, & Nothnagle 2016; Lunda, Minnie, & Benadé 2018; Ochapa et al. 2023; Oparah et al. 2021; Sayyad et al. 2023; Thomas et al. 2023; Van Eijk et al. 2022). This may be particularly true for doulas who work with birthing people who experience obstetric racism or with families who do not share a common language or culture with their medical providers. These doulas may see their role as assisting their client’s access to higher quality safe care, by making sure that there is clear communication and agreement between the medical team and their patient, and that the patient’s choices, pain, and requests for support are respected and protected.

Some doulas, particularly Black doulas who regularly confront obstetric racism and its potential outcome of mortality, use a wider range of advocacy skills, depending on the unique scenario (Arteaga et al. 2023; Cancelmo 2021; Davis 2022; Salinas, Salinas, & Kahn 2022).

Advocacy techniques doulas may use

The following are some examples of advocacy techniques used by doulas.

Here are some more subtle advocacy techniques:

• Encouraging you or your birth partner(s) to ask questions and speak up about your preferences.

• Asking you what you want.

• Verbally supporting and reminding you of your decisions.

• Creating space and time for you and your birth partner(s) to ask questions, gather evidence-based information, and make decisions without feeling pressured.

• Coaching you and your birth partner(s) on positive communication techniques to use with your medical team. This can include asking canned questions to reinforce knowledge or to gently encourage medical staff to remember a client’s birth plan or birth preferences.

• Facilitating clear communication and a sense of collaboration between you and your care providers.

• If you are not aware that a provider is about to perform an intervention, the doula could point out what it appears the nurse or physician is about to do and ask you if you have any questions about what is about to happen. For example, if it looks like the provider is about to perform an episiotomy without your consent: “Dr. Smith has scissors in her hand. Do you have any questions about what she wants to do with the scissors?”

And here are some more direct advocacy techniques a doula may use:

• Amplifying your voice if you are being dismissed, ignored, or not heard. For example, the doula could say, “Excuse me, [insert client’s name] is trying to tell you something. I wanted to make sure you heard them.”

• Telling a provider to stop if they actively perform an intervention on a client who is refusing. For example, the doula could say, “Stop, she said no to the episiotomy.” Or asking the client “Do you consent to this procedure?”

• Filling communication gaps between family, friends, or visitors and what’s happening in the birthing room (i.e. explaining when they can come in, or why it’s not a good time).

• Asking to speak with a nurse in the hallway and informing them that using specific terms or gestures could be triggering a trauma response in the client that will make their job more challenging down the line, and could have an impact on parent or baby health outcomes.

• Informing the nurse or physician that they need to provide an interpreter to gain informed consent.

• Reminding the care team that you requested no students, so there cannot be a series of students sent into the room to perform repeated cervical exams on you.

• Right before the baby is born, reminding the care team of your wish for delayed cord clamping.

• Alerting the care team to concerning signs or symptoms, such as excessive blood loss or signs of preeclampsia.

Obstetric violence and the limits of advocacy

The term obstetric violence was coined by Latin American activists to describe violence that can occur within the field of obstetrics. Although other terms such as “traumatic birth,” “mistreatment,” “abuse,” and “disrespectful care” are also used, here at EBB we choose to use obstetric violence to describe traumatic events and/or physical or emotional harm caused by prenatal or obstetric health care staff before, during, or after giving birth (van der Waal et al. 2022).

Although parents may hope their doula’s advocacy can help protect them from obstetric violence, the reality is a lot more complicated. Doulas can help you advocate for yourself and may act as a buffer, but ultimately the doula also has to negotiate with strong power dynamics on a hierarchical medical team, where the most educated provider is often seen as the authoritative decision maker.

When selecting a doula, it is important to ask your doula what their beliefs are about advocacy in the birth room. What is their past experience in tough situations? What strategies seemed to work best? They should share with you the approach they take, and which types of advocacy they do and do not provide. Birthing people can also reflect on the type of advocacy support they want from a doula and directly share this information with any doula they are considering working with. When selecting your medical provider or birth center, pay attention during appointments or visits to how your provider communicates with you and how you feel afterwards. This can be an important source of information that you can use to avoid working with a provider who makes you feel unheard, disrespected, or unsafe.

As Cristen Pasccuci, advocate and expert in preventing obstetric violence, states:

“Unfortunately, I’ve had many conversations with mothers who experienced obstetric violence with their doula present and who felt betrayed or even traumatized by what they felt was their doula’s lack of advocacy, as well as conversations with doulas distraught that they could not protect their clients from abusive providers. We have to hold a lot of nuances to talk about this.Most doulas in the U.S. are constrained in their ability to advocate to the fullest because of power dynamics and systemic realities their clients may not even be aware of, and doulas absolutely cannot prevent all mistreatment in birth—it’s more like harm reduction. And, while many doulas are skilled, experienced advocates, others are not trained in advocacy skills even if they are willing to advocate, and some doulas believe it is not their job to advocate.So, it’s really important for parents and doulas to have open and transparent conversations about their expectations and plan for what advocacy will actually look like in the birth room.”

Cristen Pascucci, founder of Birth Monopoly

What is not included in doula support?

Doulas are not medical professionals, and in general, the following tasks are not performed by doulas:

• They do not perform clinical tasks such as cervical exams or fetal heart monitoring.

• They do not give medical advice or diagnose conditions.

• They do not make decisions for the client (medical or otherwise).

• They do not pressure the birthing person into certain choices just because that’s what they prefer.

• They do not take over the role of the partner.

• They do not catch the baby.

• They do not typically change shifts (although some doulas may call in their back-up after 12-24 hours; and some volunteer doulas may take assigned shifts).

However, some doulas may also wear another “hat” as a health care professional! It is not uncommon to meet labor and delivery nurses or midwives who have also trained as doulas. Some birth professionals who hold multiple credentials may refer to themselves and offer services as a monitrice. A monitriceis a licensed or certified health professional (such as a labor and delivery nurse, a certified practicing midwife, a certified nurse midwife, etc.) who also offers doula care services. The monitrice has the training and scope to offer services in the home setting such as checking vital signs, monitoring fetal heart tones, or performing a cervical check upon request.

For example, a monitrice might perform a cervical check to confirm that you are in active labor before heading to the hospital. Once at the hospital, they function as a doula (because they are not functioning in a staff nurse or midwife role) but can also share information with their client based on their training and certification as a licensed professional. Most doulas are not monitrices, so if you are interested in this type of care, you will want to seek out someone who is a licensed nurse or midwife, has experience working as a doula, and is comfortable combining their roles in this way.

Can my friend or family member serve as my doula?

A lay doula is a partner, friend, or family member who has attended births informally, or has given birth themselves, but does not have formal training as a doula. Emerging research suggests there are benefits to working with a lay doula!

In 2020, researchers looked at the relationship between having a labor companion present at birth and exposure to mistreatment in childbirth across four countries (Myanmar, Ghana, Guinea, and Nigeria). They found the presence of a labor companion, even one with no formal training in labor support, helped protect birthing people from mistreatment in childbirth (Balde et al. 2020).

In a 2019 Cochrane Review on labor companions during childbirth, researchers reviewed 51 studies, primarily (but not entirely) from high-income countries about self-identified women’s experiences in childbirth (Bohren et al. 2019b). They found that the labor companions positively influence the dynamic between birthing women and health care providers. The presence of labor companions helped protect women from mistreatment in childbirth, and improved outcomes because they noticed and called attention to potential issues throughout labor and birth. The researchers also found that most birthing women in the studies both wanted and benefited from the presence of a labor companion, whether it was a trained professional or a family member, partner, or friend.

In a 2022 systematic review, researchers combined nine studies with nearly 7,000 participants to explore the benefits of female relatives acting as lay doulas (Nguyen & Heelan Fancher 2022). The results showed that birthing people consistently reported positive birth experiences when their female relatives served as lay doulas. However, the lay doulas’ impact on the rate of Cesareans and length of labor was inconsistent – some studies showed a positive impact, while others found no difference. Overall, this review concluded that the positive benefits of continuous labor support were most beneficial when provided by a formally trained doula, who is not part of the hospital staff.

Can my spouse or partner serve as my doula?

“She [the doula] helped him a lot out with getting him ready for when I had the baby, because I don’t think he was going to know what to do. But he was helping me breathe and stuff.” (Thullen et al. 2014)

Some people think that they do not need a doula because their partner will be with them continuously throughout labor. It is true that a birth partner(s) is an essential support person for a birthing person to have by their side. However, the birth partner will need to eat and use the bathroom at times, and they may also need support in their own emotional journey. For example, if your birth companion is becoming a parent for the first time, they may be struggling with a lack of hospital support for them as they transition into a new role (Hodgson et al. 2021; van Vulpen et al. 2021).

Also, many partners have limited knowledge about birth, labor positions, medical procedures, or what goes on in a hospital, while doulas have knowledge and experience about all these things that they can use to inform and support both the partner and birthing person. Ideally, doulas and partners can work together to make up a labor support team.

In one landmark study that evaluated the effects of doulas and fathers working together, researchers found that combining a supportive partner and a doula significantly lowered the risk of Cesarean compared to just having a supportive partner alone. In 2008, McGrath and Kennell randomly assigned 420 first-time birthing women to have routine care (including a supportive partner) or care that also included a professional doula whom they met for the first-time during labor. All the women in the study were classified as having middle- to upper-class financial income levels, having supportive partners, and being in the care of obstetricians.

During labor, doulas provided continuous support, including encouragement, reassurance, and physical support. They helped the partner support the laboring person and were careful to respect the partner’s role.

The results showed a substantial improvement in outcomes for women who had both a birth partner and a doula, compared to having a birth partner alone. The Cesarean rate for these first-time mothers was 25% in the group with a partner only, and 13.4% in the group with a partner and doula. The women who had their labor medically induced experienced an even more striking decrease in the Cesarean rate with a doula—the Cesarean rate with labor inductions was 58.8% in the group without a doula, and 12.5% in the group with a doula. Also, fewer women in the doula group required an epidural (64.7%) compared to those without a doula (76%).

Research has shown that the most positive birth experiences for fathers were ones where they had continuous support by a doula or a midwife. In the McGrath and Kennell study, the women and their partners who had a doula overwhelmingly rated the support of their doula as positive—with 93% rating their experience with the doula as very positive, and 7% as positive.

In other studies, fathers have said that when they had labor support from a midwife or doula, things were explained to them, their questions were answered, their labor support efforts were guided and effective, and they could take breaks from the emotional intensity of the labor without abandoning their laboring partner (Johansson 2015). Doulas can educate partners not only about birth, but also about how to advocate for the birthing person (Ochapa et al. 2023; Oparah et al 2023).

Doulas also provide important support for birthing people who are single parents, as well as for birthing people whose partners are unable to be present during labor and birth. In EBB Podcast 114, we speak with a solo parent about her birth story and the role her doula played in supporting her. And in EBB 303, a military spouse shares how doulas supported her throughout labor while her partner was deployed.

How is a doula different from my labor & delivery nurse?

During hospital births, doulas spend more time with you than other members of the obstetric team, such as nurses (Lucas & Wright 2019). The primary task of a labor and delivery nurse is to provide clinical care. That does not mean that a labor and delivery nurse does not provide any labor support—sometimes they do! However, they also must care for other patients and can only spend a limited amount of time in your room. Labor and delivery nurses are also mentally attending to two patients every time they enter your room: you and the baby (or babies). So, their clinical focus and decision making may sometimes be focused on the fetal monitor and not on you.

In one research study that took place in the U.S., nurses spent about 31% of a person’s labor in the room with them. Most of the time that nurses were in the laboring person’s room, they were doing direct clinical care (such as administering medications or performing interventions), maintaining equipment, applying, and assessing the output from the electronic fetal monitor, or documenting at the computer. For 12% of each person’s labor in the study, the nurse provided labor support including emotional, physical, or informational support, or advocacy. More experienced nurses were more likely to spend time providing emotional support (Barnett et al. 2008).

Three other studies in Canada have found similar findings—that nurses spend about 50-75% of their time outside the birthing person’s room. In addition to caring for their assigned client, nurses have many other responsibilities, like communicating with care providers, taking care of other clients, covering for other nurses’ breaks, documenting care, and assisting on the labor unit as necessary (Gagnon & Waghorn, 1996; McNiven et al. 1992; Gale et al. 2001).

Nurses are employed by the hospital and while they see themselves as patient advocates, they also have an interest in satisfying their employer, doctors, and midwives. By contrast, the primary responsibility of an independent doula (one not employed by the hospital) is to you.

Nurses may also go off shift during your labor, at which point their support ends and another nurse takes over your care. Most doulas, on the other hand, remain with you throughout your labor and birth whether it is long or short. Most will also plan with you about how and when to include a back-up doula in your care, to ensure you receive the continuous care and attention you need.

Both doulas and nurses may touch you at different points during labor. Doulas may use touch to provide counter-pressure, soothe you, help you get into a desired laboring position, or assist with other comfort measures. If you met your doula prior to giving birth, they may have discussed with you what physical support might look like during birth and practiced comfort or support techniques with you ahead of time.

Nurses may also provide physical support during or after labor. They may help you change laboring positions, help you feel clean during labor by changing the bedding, or help you with toileting after birth. What is different is that nurses will also perform medical tasks—such as placing an IV, assisting with inserting a Foley bulb catheter or device, conducting a cervical exam, or putting pressure on your abdomen after the birth. Some of these forms of touch may be unpleasant, and all require consent from the birthing person (but sometimes consent is not obtained). When and how a doula touches is up to the person giving birth, and their touches bring measures of comfort rather than discomfort—so your brain and body are probably trained to respond to the doula more positively over time (Personal communication, A. Gilliland 2017).

While the roles of a doula and of a labor nurse are distinct from one another, they are both united in providing support to enhance your health and wellbeing. Despite this, sometimes friction can arise if nurses are unsure of the role of a doula, or if they don’t know what forms of support the client would prefer to receive from their doula versus from their nurse. Sometimes nurses may believe (accurately or inaccurately) that a doula is overstepping their role and interfering with the nurse’s duties (Ballen & Fulcher 2006; Neel et al. 2019). But many nurses have a positive attitude towards doulas and value what they bring to the birth room (Ballen & Fulcher 2006; Neel et al. 2019).

Educating health care workers about the role of doulas, as well as facilitating clear communication between doulas, birthing people, and nurses about needs and expectations can reduce potential sources of conflict and promote better teamwork between doulas and nurses (Lucas & Wright 2019; Neel et al. 2019; Roth et al. 2016).

What is the evidence on doulas?

Cochrane Review (2017)

In 2017, Bohren et al. published an updated Cochrane review on continuous support in childbirth. They combined the results of 26 trials with more than 15,000 people across 17 countries including North America, South America, Europe, the Middle East, Africa, Asia, and Oceania, in both high-income and middle-income settings.

People in these studies were randomly assigned (like flipping a coin) to either receive continuous, one-on-one support during labor or “usual care.”

The Cochrane reviewers said the overall quality of the evidence was low quality, according to the GRADE system for assessing evidence. An important part of analyzing this study is understanding the reason for the low rating.

In the GRADE system, the quality of evidence for each outcome is rated as high, moderate, low, or very low. A GRADE rating of high would be considered great evidence—and that the authors can be confident that the true effect of doulas is very close to the effect seen in the study results. On the other hand, a rating of very low means that there is little confidence in the findings, and that the true effect of doulas could be very different than what was seen in the study results. The two middle ratings of moderate and low aren’t great, but they aren’t weak, either. In a clinical trial, it’s preferable to hide, mask, or “blind” everyone as to which treatment is being given, to avoid the placebo effect. Since it is not possible to blind participants or care providers as to who has doula support (doulas aren’t invisible!), the quality of the evidence for doulas automatically received a lower grade.

In this review, continuous support was provided either by hospital staff, such as a midwife or nurse (nine studies), doulas who were not part of the family social network and not part of hospital staff (doula, eight studies; childbirth educators, one study, retired nurses, one study), or a companion from the family’s social network, such as a female relative or a partner (seven studies). In 15 studies, the partner was not allowed to be present at birth, and so continuous support was compared to no support at all. In all the other 11 studies, the partner was allowed to be present in addition to the person providing continuous labor support.

Overall, birthing people 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 Cesareans. In addition, their labors were shorter by about 40 minutes on average, and their babies were less likely to have low Apgar scores at birth (an Apgar score is a measure of a baby’s immediate health at birth). There was some evidence that doula support in labor lowered rates of postpartum depression. There was no evidence that there are any negative effects of doula support.

The results of this study mean that continuous support, including support from a doula, is a safe and beneficial way to increase the likelihood of better outcomes for the birthing person and the baby.

How did doulas compare to the other types of continuous support?

The Cochrane reviewers also looked to see if the type of support made a difference. They wanted to know—does it matter who provides continuous labor support? Does a midwife, doula, or partner, friend, or relative offer more benefit? The researchers were able to look at this question for six topics: use of any pain medication, use of Pitocin® during labor, spontaneous vaginal birth (a vaginal birth that happens on its own), Cesarean, admission to special care nursery after birth, and negative birth experiences.

For two of the health outcomes below (designated with asterisks*), the best results occurred when a birthing person had continuous labor support from a trained doula– someone who was NOT a staff member at the hospital and NOT part of their social network.

The researchers found that overall, continuous support during birth leads to a:

• 25% decrease in the risk of Cesarean; the largest effect was seen with a doula (39% decrease)*

• 8% increase in the likelihood of a spontaneous vaginal birth; the largest effect was seen with a doula (15% increase)*

• 10% decrease in the use of any medications for pain relief; the type of person providing continuous support did not make a difference

• Shorter labors by 41 minutes on average; there is no data on if the type of person providing continuous support makes a difference

• 38% decrease in the baby’s risk of a low five-minute Apgar score; there is no data on if the type of person providing continuous support makes a difference

• 31% decrease in the risk of being dissatisfied with the birth experience; this risk was reduced with continuous support provided by a doula or someone in their social network (family or friend), but not hospital staff

The rate of special care nursery admissions was no different between people who received continuous support and those who received usual care.

It’s important to note that these decreases in risk are relative risk reductions—which requires you to carry out a math formula to understand the true reduction in risk. Relative risk is the risk of something happening to you in comparison to someone else. Absolute risk is the actual, or true risk of something happening to you.

Why are doulas so effective?

There are several reasons why resear

chers think doulas are so effective. The first reason is the “harsh environment” theory. In most countries, ever since birth moved out of the home and into the hospital, people in labor are frequently submitted to institutional routines, high intervention rates, staff 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, let alone in a vulnerable state and while managing the physical and emotional intensity of labor. These interruptions, distractions, encounters with strangers, an unfamiliar environment, and sometimes painful procedures can slow down labor and chip away at your focus and self-confidence. A doula “buffers” this harsh environment by providing continuous support, helping you to regain your focus, and providing encouragement and trusted companionship which promotes self-esteem (Hofmeyr et al. 1991).

A second reason doulas are effective is because doulas are considered a form of pain relief in themselves (Hofmeyr et al. 1991). With continuous support, you are less likely to request an epidural or pain medication. It is thought that there is less use of medication because many people with a doula feel less pain, are less likely to need an epidural, and may avoid the cascade of medical interventions that often go along with an epidural, including Pitocin® augmentation and continuous electronic fetal monitoring (Caton et al. 2002). Theoretically, the soothing touch of a doula may also help your body pay less attention to pain signals, a phenomenon known as the Gate Control theory of pain relief.

The research result—that people with doulas are less likely to have an epidural—is not due to the fact that clients with doulas in these studies were more likely to want these things up front and were more motivated to achieve them. In fact, randomized trials account for these differences—this is why they are called randomized, controlled trials. The people assigned to have a doula and those assigned to not have a doula are randomly assigned, meaning that the same percentage in each group would be planning a medicated or unmedicated birth.

A third reason why doulas are effective has to do with the attachment between the birthing person and doula which can lead to an increase in oxytocin, the hormone that promotes labor contractions. This theory was proposed by Dr. Amy Gilliland in her 2010(a) study about effective labor support.

In personal correspondence with Dr. Gilliland, she wrote, “I believe the doula effect is related to attachment. When the mother feels vulnerable in labor, she directs attachment behaviors to suitable figures around her, who may or may not be her attachment figures (parent, mate). When the mother directs attachment seeking behaviors to the doula, the experienced doula (25 births or more) responds in a unique manner. She is able to respond as a secure base, thereby soothing the mother’s attachment system. The accompanying diminishment in stress hormones allows for a surge in oxytocin in both the mother and the doula… theoretically, oxytocin is the hormone that promotes labor contractions. This theory was proposed by Dr. Amy Gilliland in her 2010(a) study about effective labor support.

In personal correspondence with Dr. Gilliland, she wrote, “I believe the doula effect is related to attachment. When the mother feels vulnerable in labor, she directs attachment behaviors to suitable figures around her, who may or may not be her attachment figures (parent, mate). When the mother directs attachment seeking behaviors to the doula, the experienced doula (25 births or more) responds in a unique manner. She is able to respond as a secure base, thereby soothing the mother’s attachment system. The accompanying diminishment in stress hormones allows for a surge in oxytocin in both the mother and the doula… theoretically, oxytocin is the hormone of attachment, and it is released during soothing touch and extended eye contact, which are habitual behaviors of birth doulas.” (Personal communication, Dr. Amy Gilliland 2015).

Swedish oxytocin researcher Kristin Uvnas Moberg writes that the doula enhances oxytocin release which decreases stress reactions, fear, and anxiety, and increases contraction strength and effectiveness. In addition, the calming effect of the doula’s presence increases your own natural pain coping hormones (beta-endorphins), making labor feel less painful (Uvnas Moberg 2014).

A study in Iran compared first-time parent’s anxiety and pain levels with doula support to those without doula support (Ravangard et al. 2017). They randomly assigned 150 first-time births to either doula support, or no doula support, and used standard questionnaires to measure anxiety and pain levels. They found that on average, those who received doula support had less anxiety and lower average pain scores during labor. The authors concluded that the doula’s presence has a clinically meaningful impact on anxiety and pain levels in first-time births. They recommend that all hospitals and maternity care centers in Iran provide access to doulas since having a safe and calm delivery is considered a human right.

Based on the evidence, our team at Evidence Based Birth® came up with a conceptual model of how doula support influences outcomes. A conceptual model is what researchers use to try and understand how a phenomenon works. Here is our conceptual model on the phenomenon of doula support:

Are doulas welcome at every hospital?

Even though doulas improve birth outcomes, many hospitals around the world do not welcome their presence. Researchers have been studying what the barriers to doula care are, in hopes that we can overcome these obstacles.

In 2019, a Cochrane review (Bohren et al. 2019b) asked how birthing people, partners/family, and health care workers felt about working with doulas. They also asked, why is continuous support not provided more often, given the many research benefits that have already been published? The three main goals of this study were to:

• Describe how the entire birth team feels about the presence of a labor companion.

• Identify why some places are better able to include labor companions.

• Support and build on the findings from the 2017 Cochrane review on labor companions.

The 2019 review combined 51 qualitative studies (text data from interviews and focus groups) published in English, French, Spanish, Turkish, and Norwegian. The studies were located across 23 countries, including 17 studies in North America, 14 in Europe, 7 in Africa, 5 in the Middle East, 3 in South America, 3 in Oceania, and 2 in Asia, and covered high, medium, and low-income settings.

The researchers stated the overall quality of the evidence as high or moderate, according to the GRADE-CERQual system of rating qualitative evidence. Different types of continuous support were included, ranging from lay companions such as a male partner, female relative, or friend, to trained doulas or student midwives. Support could be given only during labor, or in a model that includes prenatal and postpartum visits. Most studies described what it felt like for a birthing person to have a continuous support person with them in labor. Some studies shared perspectives from partners, nurses, midwives, and/or doctor, or other key stakeholders such as hospital administrators and policy makers.

Three key themes helped explain why doulas are not yet standard in birth:

1. Labor support and emotional support are still perceived as lower priorities than physical health and medical care, especially in low-resource areas.

Labor support may be viewed as “nice to have,” but not essential, especially in communities with low resources. Some people on the birth team, even the person giving birth, may feel that emotional and physical support strategies like hand holding, massage, or encouragement are unnecessary, or could be done by a nurse or other hospital staff. Especially in smaller buildings, it is thought that there is not enough space, beds, or chairs for labor companions. In places where a labor companion is required to wear hospital attire, resources may be too low to provide the clothing. Although the evidence shows that this kind of support improves birth outcomes both for parents and babies, in low resources settings where there is limited access to even lifesaving procedures, this level of care can be seen as pulling time and resources away from saving lives.

1. Not all birth settings welcome labor companions.

Many birth settings still formally forbid labor companions from being part of the birth team. Labor support will not be possible in these settings until a formal policy change is made, shared with families, and health care providers are informed that they must comply with the new policy. Still, competing priorities can arise, such as fear of labor companions increasing the risk of infection, lack of space on days when the labor unit is crowded, or privacy concerns around male companions in areas with open floor plans (where only thin curtains separate patients from each other). For example, in Brazil, labor companions are allowed at all births by law, but some providers refuse to allow a companion to enter the room if they think the companion is unprepared or needs “supervision,” or if the patient is poor or uninsured.

1. Health care staff are not prepared to work together with doulas or value what they bring to the team.

Nurses, midwives, and doctors can have prejudices that lead to them resisting the presence of doulas or labor companions. Doulas bring a unique perspective into the birth room that may be perceived as “clashing” with the way hospital staff approach birth. Hospital staff may see themselves as superior because of their years of training, strict protocols, and practice guidelines in physical health and medical care that they are supposed to follow. To them, a lay person coming in to support labor and offer emotional care can seem unprepared, untrained or “anti-medical establishment.” Instead of focusing on rules, policies, and medical emergencies, doulas provide companionship, informational support, emotional support, a sense of safety and calm, and advocacy, which can be seen as at odds with health care staff who have specific tasks that they want to accomplish and a goal of patient compliance with hospital policies and protocols.

In the eyes of hospital staff, doulas can be seen as lacking purpose or appropriate boundaries, or as someone who “gets in the way.” Providers think they must “manage” this extra person, adding to their already full workload, and they may fear being evaluated, misunderstood, or judged for their clinical decisions by someone they view as having no understanding of birth physiology or medicine. Some midwives and nurses may worry that doulas will take over their caring and nurturing role, which may be one of the reasons why they chose this field, while others may appreciate the extra help so that they can better focus on clinical tasks.

Labor companions can also feel frustrated by not having enough training or direction on how to help with difficult births or how to interact with medical staff. They may offer advice or intrude on the roles of medical staff if they think their client’s safety or birth preferences are at risk. They may notice when they are not valued by medical staff, and become defensive to all future medical providers, anticipating challenges and successfully navigating their role, but at the cost of losing hope for creating collaborative partnerships with medical providers.

Doulas and health care staff each address a different and important element of caring for someone in labor. When they are trained on how to respect each other’s roles in a spirit of cooperation rather than conflict, most providers agree that doulas are a valued part of the birth team. But when doulas are not well integrated, they can be ignored and actively excluded from care giving. Providers may feel frustrated, unsure how to “manage” the doula, and fear that their patients with doulas will create conflict, have more physical pain, or refuse to follow medical advice.

Here at EBB, we have witnessed another phenomenon, which is that some providers do not believe someone can give birth without another person in control of them and their choices. These providers assume that the doula is there to “control” the birthing person in place of the doctor. They may see the birthing person’s autonomous choices as being made by the doula simply because a doula is present. This perception leads the provider to view the doula as a threat to the provider’s need to have authority over the birthing person.

Based on the 2019 Cochrane review, here are seven questions to find out how well prepared a birth setting is to welcome birth companions:

• Are providers trained on the benefits of labor companions?

• Are patients educated on the benefits of labor companions?

• Is the birth setting structured in a way to ensure privacy?

• Are providers trained on how to include companions as valued members of the birth team?

• Are there clear roles and expectations for both companions and providers?

• If your companion is a lay person (and not a trained doula), does your birth setting offer prenatal training to help your companion learn how to provide labor support?

• Is the pregnant person permitted to choose their own companion(s)?

If having labor support is important to you, please share the evidence from this Signature Article on Doulas with your providers, so that doulas can be more integrated, understood, and welcomed in the future.

Other global issues faced by doulas

Doulas practice in hospitals and birthing centers and at home births around the world. While a passion for birth and for supporting birthing people may unite doulas, the everyday experience of being a doula can vary significantly.

In many countries, medical professionals are still not familiar with doulas or what they do. This means many medical professionals are uncomfortable with the presence of a doula in the labor room. In some medical systems, the presence of a birth companion is not always allowed, and birth companions can be easily dismissed from the labor room, which can make it difficult for doulas to provide continuous support and care during labor and birth.

Many doula trainings are based in North America or Europe or developed by organizations based in these regions. As a result, the trainings and resources provided by these organizations may not be applicable to the experiences and needs of doulas and clients who come from different cultures, or who are working and birthing in different medical systems.

In the resources section at the end of this article, we include resources about how to find a doula, as well as links to EBB podcasts with doulas around the world.

What is the bottom line?

Evidence shows that continuous labor support is one of the most important and basic needs of birthing people. And evidence clearly shows that a doula’s presence improves birth outcomes! Continuous labor support can lower the chances of needing a Cesarean, lower the use of medications for pain relief, and lower the risk of newborns experiencing a low five-minute Apgar score (Bohren et al. 2017; Gilliland 2010b; McGrath & Kennell 2008; Nguyen & Heelan Fancher 2022).

Doulas improve birthing people’s satisfaction with their birth and provide an important source of physical, emotional, informational, and advocacy support for both the birthing person and their birth partner(s) (Bohren et al. 2019b; Johansson 2015; Mallick, Thoma, & Shenassa 2022). Doulas are not medical professionals, but their value in making childbirth safer and more supported has been recognized by leading professional medical organizations and by nurses and other medical staff who report having positive attitudes towards doulas (Ballen & Fulcher 2006; Neel et al. 2019).

Research has not shown any medical risks to having a doula. However, there may be some potential drawbacks if the birthing person has expectations of advocacy that their doula is unable to fulfill. In addition, when working with any professional, there is the risk that the person you hire may not fulfill their obligations to you. Speaking to a doula’s former clients is an important way to vet your doula.

Doulas are a diverse group with a range of perspectives on and approaches to birth. Not every doula is the best fit for every birthing family—you may need to meet with several before you find the right person. Likewise, doulas may decline to work with a client who has expectations they cannot fulfill, who behaves towards them in an abusive or inappropriate manner, or who is otherwise dishonest towards them in their dealings. Before signing any agreement, it is important for the doula and the client to both clearly outline their expectations and approaches to birth and come to a mutual understanding.

Doulas are trained to provide support to birthing people during pregnancy, labor, and birth—but they do so much more! Doulas engage in a wide range of forms of care and support. Some doulas care for people prior to conception, during abortions, during and after a miscarriage, in the weeks after childbirth, and at the end stages of life. There are many different types of doulas, who draw on many different types of trainings, certifications, traditional cultural or faith-based practices, and perspectives on childbirth in their work to support birthing people before, during, and after childbirth.

Research shows what many families already know: a doula can make a big difference in your childbirth experience. However, having a doula is not a magic wand. Doulas often work in broken health care systems in the face of oppression, racism, homophobia, transphobia, and other “isms.” Doulas need all our support in advocating for safer, more supportive birth settings. The doula’s role can also be made more difficult if you and/or your birth partner(s) have limited knowledge about birth options when you go into labor. Educating yourself about birth as much as possible beforehand can equip you with skills that will enhance the doula’s labor support.

For those considering becoming a doula, it is important to consider what types of training you want to pursue and what your own approach to this type of birth work will be. It is also important to recognize that this can be a demanding field where you may be exposed to challenging situations and traumatic births. Seeking out community support from other doulas can help you to process difficult emotions and avoid burnout.

In conclusion, doulas provide important benefits for their clients, birthing families, and communities, as well as for hospitals and medical systems. Therefore, doulas should be viewed and valued by both parents and providers as valuable, evidence-based members of the birth care team, whose presence can improve health outcomes for parents and babies.