Intrapartum Doula Support and Cesarean Delivery Rates: A Systematic Review and Meta-analysis

Abstract

OBJECTIVE:

To estimate the association between doula support and cesarean delivery compared with standard of care.

DATA SOURCES:

We conducted a systematic review of randomized controlled trials (RCTs) and observational studies comparing in-person intrapartum doula support with standard care. We searched studies published in Ovid Medline, Embase.com, Scopus, Cochrane Central, and ClinicalTrials.gov before August 30, 2024. The primary outcome was cesarean delivery. Secondary outcomes included operative vaginal delivery, low 5-minute Apgar score, and regional anesthesia.

METHODS OF STUDY SELECTION:

Titles, abstracts, and manuscripts were screened and reviewed by two authors. Eighteen studies were included in the final analysis (n=367,662): 8 RCTs (n=2,497) and 10 observational studies (n=365,165). The primary analysis was restricted to RCTs. Additional analyses were limited to studies that were observational, high quality (Downs and Black quality score in top quartile), or RCT’s conducted in the U.S..

TABULATION, INTEGRATION, AND RESULTS:

Random-effects models were used to calculate pooled relative risks (RRs) and weighted mean difference. Heterogeneity was assessed with the Cochran Q test and I² statistic. Intrapartum doula support was associated with a lower rate of cesarean delivery compared with standard care in RCTs (n=7: 17.5% doula support vs. 23.6% standard care, pooled RR 0.71; 95% CI 0.53–0.95). However, there was substantial study heterogeneity (I²=60.1%) and borderline evidence of small-study effects, which could suggest publication bias (Harbord’s Test p=0.046). Patients receiving intrapartum doula support in RCTs had significantly lower rates of operative vaginal delivery (n=5: 7.9% doula support vs. 13.2% standard care; pooled RR 0.64; 95% CI 0.44–0.94; I²=46.0%),, but no difference in low 5-minute Apgar score (n=3: 1.6% doula support vs. 4.1% standard care; pooled RR 0.47; 95% CI 0.16–1.34; I²=0%) or regional anesthesia (n=7: 57.3% doula support vs. 69.5% standard care, pooled RR 0.64; 95% CI 0.36–1.12; I²= 98.75%). Findings were similar in a sensitivity analysis limited to high-quality studies. Doula support was associated with lower cesarean delivery rates among all sub-group analyses except RCT’s in the United States (4 studies: 16.1% doula support vs. 22.2% standard care; pooled RR 0.71; 95% CI 0.47–1.06).

CONCLUSION:

Intrapartum doula support was associated with lower rates of cesarean delivery. Results were consistent across study types and when limited to high quality studies; however, significant heterogeneity and concern for publication bias were noted.

SYSTEMATIC REVIEW REGISTRATION:

PROSPERO, CRD42023423577.

Précis:

Intrapartum doula support was associated with lower cesarean delivery rates.

INTRODUCTION

Cesarean delivery rates have steadily risen since 1970 and now account for more than one-third of all deliveries.^1–3 During the same period, there has been a commensurate rise in abnormal placentation and maternal morbidity and mortality.^3–5 Although cesarean delivery can be a lifesaving procedure for the patient or baby, surgical intervention without clear evidence of a reduction in maternal or neonatal morbidity raises significant concern that this procedure is overused.^6–9 It is important to note that the burden of cesarean deliveries and associated morbidities are not borne fairly nor equitably across the U.S. population, with American Indian, Asian, non-Hispanic Black and Latina patients more likely to undergo cesarean delivery than non-Hispanic White patients.^10,11 Interventions to reverse the trend have largely failed due to its perceived relative safety by patients and clinicians, expeditious nature, ability to be conducted upon patient request without medical indication, and the current medicolegal environment.¹² A notable exception, that shows promise in curbing this trend, is intrapartum doula support.¹²

Doulas are trained professionals who provide non-medical emotional, physical, and informational support and advocacy before, during and after childbirth.¹³ In addition to intrapartum support, professional doula services may include home visits throughout pregnancy, continuous support at home during latent labor, home visits to support recovery and parenting after birth, and phone or text communication during this entire period. A study of the SisterWeb San Francisco Community Doula network found that for each hour doulas spent with clients attending medical visits, they spent 2.15 more hours communicating with them in other ways for a total of 32 hours over the course of the pregnancy and postpartum course, on average.¹⁴ Prior studies suggest that doula support during labor is associated with a reduction in cesarean birth,^15–17 preterm birth,^15,18 and low birthweight.¹⁸ A Cochrane review from 2017 showed that continuous labor support, inclusive of—but not limited to — doulas, was linked to numerous improvements in birth outcomes, including decreased instrumental deliveries, intrapartum analgesia, and greater satisfaction with the birth experience.¹⁹ The continuity of care during labor is informed by the proximal relationship of doulas with their clients, providing intimate and educational resources for families to self-advocate with the intention of shared decision making and informed consent with their medical team. Despite a growing body of evidence that professional doula support is cost-effective with a savings of ~$1000 per delivery, it is not typically covered by health insurance.^20,21 This limits access to the general population, especially patients with historically marginalized identities or lower socioeconomic standing, who already experience disproportionate rates of adverse pregnancy outcomes.²² A growing number of states are beginning to offer coverage of doula support as a Medicaid benefit; yet, many implementation barriers persist in pregnant people being able to access this service.²³ The purpose of this systematic review and meta-analysis is to synthesize, update, and pool results from randomized and observational studies of intrapartum professional doula services to determine whether doula support significantly decreases the rate of cesarean delivery compared with standard intrapartum care.

SOURCES

The protocol for this review was prospectively registered with PROSPERO (ID CRD42023423577). We searched the published literature using strategies created by a medical librarian (M.D.) to identify interventions utilizing doula (non-medical personnel) support during obstetric labor. Doula support may be utilized antepartum, intrapartum, or postpartum. We elected to focus on the intrapartum period because this time interval is most relevant to the primary outcome and is the most consistently covered period by doula support services in the literature. Search strategies were established using a combination of standardized terms and keywords including but not limited to (doula OR labor coach) AND (labor OR labour OR delivery OR cesarean section OR during childbirth). Synonyms for doula were combined with cesarean delivery, such as companionship support, continuous emotional support, childbirth support person, maternity care assistant, personal support during labor, traditional birth attendant, and monitrice. The search was run on June 1, 2023, without any limits or filters in the databases Ovid Medline 1946-, Embase.com 1947-, Scopus 1823-, Cochrane Central, and Clinicaltrials.gov, and updated on August 30, 2024 (see Appendix 1 for full electronic search strategy). Results were exported to Covidence, a systematic review management system.

STUDY SELECTION

Studies were included if they were English-language articles, randomized controlled trials (RCTs) or observational studies, compared intrapartum (period between arriving at the hospital with plan for delivery through delivery of the placenta) in-person doula (professional doula with training in childbirth support) support (combination of comfort measures, information, advocacy, and/or emotional support) with standard of care, reported pregnancy outcomes, and published before August 30, 2024. We elected to include observational studies and randomized trials to both understand findings of gold-standard RCTs that minimize confounding while also including observational data with more representative and generalizable study samples.²⁴ We excluded non-original research (i.e. commentaries, notes, or editorials), cases reports, case series, review articles, studies without comparison groups, and studies of non-doula labor support (i.e. lay person with no training, family member, or member of the medical team such as a nurse or midwife).

The intervention of interest was intrapartum doula support. Study outcomes were pre-specified based on their likelihood to be influenced by doula support during labor and delivery. To be included in the analysis, pre-specified outcomes had to be included in at least two studies meeting inclusion criteria and defined in a similar manner so that the results could be pooled. The primary outcome was cesarean delivery. Secondary outcomes were operative vaginal delivery with forceps or vacuum, low 5-minute Apgar score <7, and regional anesthesia placement (Appendix 2 http://links.lww.com/xxx).

Titles and abstracts were independently screened by two authors in Covidence (Y.D. and N. A). Full-text articles were retrieved if they appeared relevant or if there was ambiguity regarding whether it was relevant. Full-text articles were independently reviewed against inclusion and exclusion criteria (Y.D. and N.A.).

Data were independently abstracted from included articles into a standardized abstraction form (Y.D. and N.A.). Any discrepancies in decisions regarding study inclusion or exclusion were resolved by discussion and consultation with the senior author (E.B.C). If data needed to be obtained from a study investigator, the corresponding author was contacted by email. Y.D. and N.A critically appraised the quality of inclusion studies using Downs and Black checklist.²⁵ We selected this validated tool because it assesses the methodologic quality of both randomized and observational studies of health care interventions. The checklist included 27 questions in the following quality categories: reporting, internal validity, external validity, power. Each study could receive a maximum score of 28 for the highest quality study. Of note, we used a modified scoring system with a single point given for adequate power compared to 5 possible points in the original study. A priori, we decided that studies with a score above the median would be considered high-quality.

Data analysis was performed with STATA (Version 18 SE, College Station, TX) using the METAN software package. Heterogeneity between studies was determined using Cochran’s Q and Higgins I² tests. Heterogeneity was considered significant with a conservative measure of P<0.1 or I²>30%. Data were pooled if there were at least two studies available for a given outcome with similar definitions. Raw data from each study were used to calculate relative risks (RR) with a 95% confidence interval (CI). Data from each study was pooled using the Restricted Likelihood Maximum random-effects models, regardless of whether there was evidence of statistical heterogeneity. We used this conservative approach, which also results in more conservative estimates of effect sizes, due to the low statistical power of tests of heterogeneity. Relative risks for each categorical outcome were plotted graphically as forest plots. The primary analysis was limited to randomized trials. Additional analyses included stratified by design (RCT or observational studies), high-quality studies (Downs and Black score ≥75^th%), and RCTsperformed in the United States. Publication bias was assessed graphically using funnel plots and asymmetry was formally tested with Harbord’s test for categorical variables.

RESULTS

The electronic literature search identified 2,282 results that were exported to Covidence. Duplicate studies (1,162) and those ineligible by title and abstract review (1068) were excluded, leaving 52 articles (Figure 1). These references underwent full text review for eligibility and 34 were excluded, leaving 18 studies meeting inclusion criteria (Figure 1). The bibliographies were reviewed for each selected paper to determine whether any potentially relevant articles were overlooked during the formal search, but none were found. Eighteen studies were included in the final analysis (n=367,662 patients), including 8 RCTs (n=2,497 with 1271 (50.9%) receiving doula support) and 10 observational studies (n=365,165 with 6,037 (1.7%) receiving doula support). Characteristics of each selected study, inclusion and exclusion criteria, and descriptions of the doula interventions are listed in Table 1)(Appendix 2, http://links.lww.com/xxx). Study quality was assessed with the Downs and Black checklist with scores ranging from 16–25 (median 20, interquartile range 19–23).²⁵ Studies were considered high-quality if their score were ≥75^th%, which corresponded to a score ≥23. Five RCTs and no observational studies met criteria for high-quality (Appendix 2, http://links.lww.com/xxx). All RCTs reported the primary outcome of cesarean delivery, but Byrskog et al.²⁶ was excluded from the primary analysis because only “emergency cesarean section” was captured in their study outcomes.

Figure 1.

Flowchart of methodology for study selection. RCT, randomized controlled trial.

Table 1.

Description of included studies

Lead Author	Title	Year Pub-lished	Country	Setting	Inclusion	Exclusion	Doula Program Description	Intrapartum Doula Support (Intervention)
Observational
Al-Zahir40	Effects of Doula Care on Mother and Infant Health Outcomes in Al-Ahsa Region, Saudi Arabia: A Retrospective Cohort Study	2024	Saudi Arabia	Primary health center in Al-Ahsa -Eastern Province	Saudi women, residents of Al-Ahsa, 18–40 years, singleton	High-risk pregnancies: smoking in pregnancy, elective CS, chronic diseases and maternal complications.	Assisting Mothers for Active, Natural, and Instinctive Birth (AMANI Birth) is an Islamically based childbirth education and doula program dedicated to empowering and supporting women in making informed decisions about their birth.	Support and assistance during delivery, not fully described.
Byrskog26	Community-based bilingual doulas for migrant women in labour and birth – findings from a Swedish register-based	2020	Sweden	Hospitals in Gothenburg	Migrant and Swedish-born women, singleton	Births with incomplete data, spontaneous or induced abortion, births recorded twice, and no matching birth in the national medical birth register	Women who were not fluent in Swedish were offered support by community-based doulas (CBD) who were bilingual in the woman’s own language and acquainted with the cultures of both countries.	During labor, the doula provided continuous emotional and physical support and facilitated communication with staff.
Chen41	Effectiveness of the doula program in Northern Taiwan	2020	Taiwan	Taiwan	No pregnancy complications, Chinese or Taiwanese speaking, consent to participate	Birth<38 weeks, fetal/neonatal death	The Birth Doula Program consisted of six trained doulas who were invited to provide the research intervention. They were led by a DONA certified doula trainer. The intervention was provided free of charge to those in need.	Services during labor and childbirth included continuous psychological support, comfort measures, information, and advocacy for women and their families.
Dundek42	Establishment of a Somali Doula Program at a Large Metropolitan Hospital	2006	U.S.	Fairview Health Services, Minneapolis, MN	Live-born infant	Women who could not be identified through birth certificate or chart information	DONA certified Somali doulas employed by the hospital providing services free of charge to patients.	On-call doulas working shift-based schedules provided support to pregnant people admitted for delivery. They arrived within an hour of being called. If the shift ended before birth, they could decide to stay or call the next doula. Provided physical and emotional support, emphasizing cultural understanding.
Falconi43	Doula care across the maternity care continuum and impact on maternal health: Evaluation of doula programs across three states using propensity score matching	2022	U.S.	Control: across the country. Doula: county in central CA; county in a Northeastern state (unidentified); FL.	Women ages 12–51 with at least one claim for a pregnancy outcome diagnosis or procedure (ICD-9 or ICD-10) and at least one day of medical eligibility in Medicaid.	*	National insurer’s pilot programs that provided covered doula services to women with Medicaid insurance. Doula care was identified using the Center for Medicare & Medicaid Services claims and National Provider Identifier codes.	Support and assistance during delivery, not fully described.
Kozhimannil22	Doula Care, Birth Outcomes, and Costs Among Medicaid Beneficiaries	2013	U.S.	Control: Nationwide inpatient sample	Control: Medicaid-funded singletons nationwide Doula: Medicaid beneficiaries receiving Everyday Miracles doula support	*	Everyday Miracles doulas is a non-profit doula program that provides services at no costs; clients referred by Medicaid managed care.	Doulas provided continuous labor support.
Lemon44	Quantifying doula association with maternal and neonatal outcomes	2024	U.S.	University of Pittsburgh Medical Center (UPMC) health system	Prenatal care received at UPMC, live birth at UPMC	Delivery <16 weeks or >44 weeks, doula care outside of program	Birth Circle Doula program integrated into the obstetric care of the hospital system. Doulas were employees of the health system and provided services at no cost to patients. Services were obtained through clinician referral, self-referral or patient outreach.	At least one encounter with a doula during delivery admission; services not described.
Mottl-Santiago45	A Hospital-Based Doula Program and Childbirth Outcomes in an Urban, Multicultural Settings	2008	U.S.	Boston Medical Center (BMC)	Singleton, live birth, ≥37 weeks	Births with missing or incorrect data.	Birth Sister program46 at BMC is designed to provide social support in the perinatal period. Services are provided free of cost. Doulas were assigned to patients in the third trimester according to cultural and language preferences.	Continuous emotional and physical support from active labor through delivery. Focused on encouragement, comfort measures and relaxation techniques. Translation assistance and advocacy was also offered.
Thomas18	Doula Services Within a Healthy Start Program: Increasing Access for an Underserved Population	2017	U.S.	Doula: Brownsville, East New York, Bedford-Stuyvesant, and Bushwick, NY Control: NYC DOHMH Department of Vital Statistics: birth outcomes for select zip codes.	Women living in the neighborhoods of Brownsville, East New York, Bedford-Stuyvesant, and Bushwick who meet income eligibility requirements for WIC	*	By My Side Birth Support Program (BMS) combines aspects of private doula practice and community-based programs to provide social support during pregnancy, labor and delivery, and the postnatal period. BMS subcontracts with 12 doulas, four of whom have been with the program since 2010.	During labor, doulas assisted pregnant women and their families in navigating the hospital environment and facilitated communication with medical staff.
Thomas47	Birth equity on the front lines: impact of a community-based doula program in Brooklyn, NY	2023	U.S.	Brownsville, East New York, Bedford-Stuyvesant, and Bushwick, NY	Doula: Living in one of six ZIP codes in central or east-ern Brooklyn and meeting the income-eligibility requirements for WIC. Control: matched by zip code and demographics.	*	BMS combines aspects of private doula practice and community-based programs to provide social support during pregnancy, labor and delivery, and the postnatal period.	Described in Thomas above.
Randomized Controlled Trials
Cogan48	Social support during premature labor: Effects on labor and the newborn	1988	U.S.	Lubbock General Hospital and Northwest Texas Hospital	26–37 weeks, <3 cm upon admission	Signs of meconium staining or fetal distress, breech or transverse, chorioamnionitis, abruption, placenta previa, or multiple gestation	Lamaze childbirth preparation teachers with additional training in childbirth support.	Provided continuous one-on-one support throughout labor after 3 cm dilation; provided information to client and family, liaison with hospital staff, taught relaxation and breathing techniques measures to the woman in labor.
Gordon49	Effects of Providing Hospital-Based Doulas in Health Maintenance Organization Hospitals	1999	U.S.	Three medical centers from a health maintenance organization in northern CA	Nulliparous, uncomplicated pregnancy, receiving prenatal care in selected hospitals, in spontaneous labor with <5 cm dilation at admission	< 18 years of age.	Hospital on-call doula service. Doulas received $75 stipend for each assisted labor.	Continuous support during labor after reaching 4 cm dilatated and during delivery.
Kennel50	Continuous Emotional Support During Labor in a US Hospital	1991	U.S.	Jefferson Davis Hospital in Houston, Texas	Nulliparous, ages 13–34, singleton, term, uncomplicated pregnancies	Pregnancy-induced hypertension, breech presentation, gestational diabetes, a history of drug or alcohol abuse, or other high-risk conditions	Eleven doulas participated in the study, with 82% of deliveries supported by four primary doulas.	The doulas provided continuous support at bedside after patients reached 3–4cm of dilation until delivery. They provided emotional support, encouragement, and explanations of labor progress. They also translated medical instructions when needed.
Langer51	Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers’, wellbeing in a Mexican public hospital: a randomized clinical trial	1998	Mexico	Large public hospital of the Mexican Institute of Social Security	Singleton, no previous vaginal delivery, < 6 cm of cervical dilatation	Evidence of any severe obstetric disease or indications for an elective caesarean section.	Retired nurses who received doula training. Of 22 trained candidates, the top 10 were selected to participate in the trial.	Doulas accompanied women during labor and birth. They provided continuous communication and emotional and physical support; information about their labor process and medical procedures; and encouraged immediate mom-baby contact.
McGrath52	A Randomized Controlled Trial of Continuous Labor Support for Middle-Class Couples: Effect on Cesarean Delivery Rates	2008	U.S.	University Hospitals in Cleveland, OH	Nulliparous women between the ages of 18 and 41 years in the third trimester, uncomplicated pregnancy, expected to be accompanied during labor by their male partner and planned to deliver under care of private OB	*	Ten women served as research doulas, with three attending 79% of the doula-supported labors. Doulas worked part-time on an on-call basis. The research grant compensated them for each labor attended.	The intervention provided continuous doula support to pregnant people and their support partner during labor and delivery. Doulas met patients within an hour of hospital arrival and stayed throughout the process. They offered individualized support through encouragement, reassurance, teaching, touch, and eye contact, while guiding partners to support the laboring woman, ensuring active involvement from both partners.
Mottl-Santiago53	Effectiveness of an Enhanced Community Doula Intervention in a Safety Net Setting: a randomized controlled trial	2023	U.S.	Urban safety net hospital	Primigravid, public insurance, between 16–24 weeks	<18 years, multiple gestation, known anomaly or high-risk pregnancy condition, suicidal ideation at baseline interview	Birth Sisters Best Beginnings for Babies enhanced hospital-based doula intervention with culturally congruent community-based doulas. The intervention group received an enhanced version of the Birth Sisters Program,46 beginning at 24 weeks.	Continuous labor and birth support, focused on emotional and physical comfort measures, and advocacy for the birthing person with the healthcare team.
Schytt54	Community-based bilingual doula support during labour and birth to improve migrant women’s intrapartum care experiences and emotional well-being–Findings from a randomized controlled trial in Stockholm, Sweden	2022	Sweden	Six antenatal care clinics and five hospitals in Stockholm	Nulliparous and multiparous, ages 18 or older, 25–35 weeks of gestation who spoke Arabic, Polish, Russian, Somali or Tigrinya, who could not communicate fluently in Swedish, had no contraindications for vaginal birth and consented to access to their birth record data.	*	A total of 23 community birth doulas (CBD) were employed to support five migrant groups. Women receiving CBD support were paired with a CBD who spoke their language.	During labor, the doula facilitated communication with the labor ward, and provided continuous emotional and physical throughout labor and birth.
Trueba55	Alternative Strategy to Decrease Cesarean Section: Support by Doulas During Labor	2000	Mexico	Public general hospital (third level institution) in Mexico City.	Full term, engaged in an active phase of labor, ≥ 3 cm cervical dilation, nulliparous, no previous uterine incision, and had adequate pelvises	*	Hospital-based doula program.	Doulas supported laboring women using comfort measures such as touch relaxation, slow and modified breathing techniques, focal point concentration, and, when possible, walking and movement. These activities were designed to facilitate the natural progression of labor and birth.

^*Information not provided in source paper

Cesarean Section (CS), United States (U.S.), Infants, and Children nutrition program (WIC), Doulas of North America (DONA)

In the primary analysis of RCTs, patients receiving doula support had a significantly reduced rate of cesarean delivery compared with standard care (n=7: 17.5% doula support vs. 23.6% standard care, pooled RR 0.71; 95% CI 0.53–0.95) (Figure 2 and Table 2). There was substantial study heterogeneity (I²=60.1%) (Figure 2) and evidence of small-study effects, which could suggest publication bias (Harbord’s Test p=0.046; Figure 3). Doula support was also associated with lower cesarean delivery rates in sub-group analyses (Table 2) of high-quality studies (n=5: 15.8% doula support vs. 22.0% standard care, pooled RR 0.70; 95% CI 0.50–0.99; I²=61.3%) (Appendix 3, http://links.lww.com/xxx) and observational studies (n=9: 22.1% doula support vs. 31.8%, pooled RR 0.77; 95% CI 0.66–0.90; I²=83.2%) (Appendix 4, http://links.lww.com/xxx). However, there was no difference in analysis limited to RCT’s completed in the United States (n=4: 16.2% doula support vs. 22.3% standard care; pooled RR 0.71; 95% CI 0.47–1.06; I²=71.1%) (Table 2, Appendix 5, http://links.lww.com/xxx).

Figure 2.

Forest plot for pooled cesarean delivery rate in doula support versus traditional care in randomized controlled trials (RCT) and observational studies. DL, DerSimonian–Laird.

Table 2.

Summary of Pooled Results Based on Random-Effects Meta-Analysis in Randomized Controlled Trials

Outcome	No. of Studies	Doula Support n (%)	Standard Care n (%)	Pooled log RR (95% CI)	I2 (%)
Cesarean Delivery	7	220/1257 (17.5)	287/1216 (23.6)	0.71 (0.53–0.95)	60.1
Operative Vaginal Delivery	5	78/982 (7.9)	128/970 (13.2)	0.64 (0.44–0.94)	46.0
Low 5-min Apgar	3	5/316 (1.6)	11/271 (4.1)	0.47 (0.16–1.34)	0
Regional Anesthesia	7	689/1202 (57.3)	782/1125 (69.5)	0.64 (0.36–1.12)	98.75

Bold values denote statistical significance as indicated by 95% confidence intervals.

Figure 3.

Funnel plot with pseudo 95% confidence limits for pooled cesarean delivery rate in doula support versus traditional care in randomized controlled trials (RCT) and observational studies.

In analysis of secondary outcomes (Tables 2 and 3), patients receiving intrapartum doula support had significantly lower rates of operative vaginal delivery in RCT’s overall (5 studies: 7.9% doula support vs. 13.2% standard care; pooled RR 0.64; 95% CI 0.44–0.94; I²= 46.0%) (Appendix 6, http://links.lww.com/xxx)) and in analysis limited to high-quality studies (4 studies: 10.5% doula support vs. 18.9% standard care; pooled RR 0.59; 95% CI 0.39–0.88; I²=46.0) (Appendix 7, http://links.lww.com/xxx), but there was no difference among observational studies (Appendix 8, http://links.lww.com/xxx) or RCT’s completed in the United States (Appendix 9 http://links.lww.com/xxx).

Table 3.

Summary of Pooled Results Based on Random-Effects Meta-Analysis of Proportions for Primary and Secondary Endpoints for all analyses

Outcome	RCT Pooled RR (95% CI) (n=2497)	High-Quality Pooled RR (95% CI) (n=1660)	Observational Pooled RR (95% CI) (n=365,165)	United States RCT’s only Pooled RR (95% CI) (n=1541)
Cesarean Delivery	0.71 (0.53–0.95)	0.70 (0.50–0.99)	0.77 (0.66–0.90)	0.71 (0.47–1.06)
Operative Vaginal Delivery	0.64 (0.44–0.94)	0.59 (0.39–0.88)	0.97 (0.72–1.30)	0.59 (0.33–1.05)
Low 5-minute Apgar	0.47 (0.16–1.34)	0.62 (0.20–1.94)	1.28 (0.95–1.73)	***
Regional Anesthesia	0.64 (0.36–1.12)	0.65 (0.32–1.33)	0.71 (0.56–0.91)	0.58 (0.24–1.38)

Bold values denote statistical significance as indicated by 95% confidence intervals.

^***Results could not be pooled because only one RCT included this outcome.

There was no difference in low-Apgar scores among any study type (Appendices 10-12, http://links.lww.com/xxx), although there were not enough studies measuring low-Apgar in the same way to pool results for RCTs in the United States. Intrapartum doula care was not associated with receiving regional anesthesia in any study type except observational studies (3 studies: pooled RR 0.71; 95% CI 0.56–0.91 I²=87.6%) (Appendices 13-16, http://links.lww.com/xxx).

DISCUSSION

We found that intrapartum doula support was associated with significantly lower rates of cesarean delivery with no difference in low 5-minute Apgar score. Doula support was associated with significantly lower rates of operative vaginal delivery when pooling RCTs and high-quality studies, but this finding was not consistent across all study types and there was no difference in regional anesthesia except among observational studies.

The notion of continuous support during labor is not new. Of 150 cultures in an anthropologic study, a family member or friend stayed with the mother during delivery in all of them, save one.²⁷ The concept of doula support in the United States gained traction in the 1960s, and literature on its effectiveness first emerged in a study published in the New England Journal of Medicine in 1980.^27,28 This randomized trial showed shorter labor among nulliparous patients and enhanced “maternal behavior” in the hour after delivery among patients randomized to doula support.²⁷ Several meta-analyses and systematic reviews of doula support in the late 1990s and early 2000s suggested improved pregnancy outcomes.^29–32 A 2017 Cochrane review of continuous support for patients during childbirth (not limited to doula support) suggested that patients receiving it were more likely to have a spontaneous vaginal birth, shorter labor, and that they were less likely to have intrapartum analgesia, operative vaginal delivery, low infant Apgar scores, or report negative feelings about childbirth, than those in standard care.¹⁹ Importantly, when data were disaggregated by the support person’s role, cesarean delivery rates were lowest when support was provided by a doula. The review was limited by inclusion of various types of continuous birth support people, of which doulas were only one example.¹⁹

We build upon prior work by updating the literature specific to doula support services with studies published through 2024, focusing specifically on non-clinician, intrapartum support services provided by professional doulas, and a sub-group analysis specifically focused on the United States. Our contemporary study findings are consistent with prior data and help to inform health policy and Medicaid priorities as we strive to implement evidence-based practices to improve intrapartum outcomes. Despite a growing body of evidence suggesting that doula support is cost-effective, best estimates suggest that only 6% of births in the United States are attended by a doula.^{33 34} Even in states that have Medicaid coverage for doula support, multiple barriers remain in accessing this service.^34,35 As one of few evidence-based interventions to curb the rate of cesarean deliveries, additional information about the effectiveness of doula support in reducing costly adverse pregnancy outcomes are necessary to inform both policy-makers and payers.

Strengths of this review include our focus on professional doulas because we excluded studies of continuous labor support provided by a clinician (ie. labor and delivery nurses or midwife) or untrained lay person or family member. Prior reviews have been limited by the generally low quality of source data, but the Downs and Black checklist, which can be applied to both observational and randomized trials, allowed us to assess the quality of each study and perform sub-group analyses that pooled high-quality studies.

Our findings should be interpreted in the context of the following limitations. First, there is significant heterogeneity in our results, which likely reflects differences in the socioeconomic background, educational level, age and insurance status of patient samples and the diverse ways in which doula support may be implemented. While Table 1 includes a description of the doula program and intervention in each source study, the information available was often limited. There may be inherent bias in which patients are able to access doula services and, despite inclusion of RCT’s to limit confounding, it is possible that the samples in the RCTs are not representative, and outcomes are not generalizable. The quality of contributing studies was generally low and the wide confidence intervals for outcomes, such as cesarean delivery in RCTs conducted in the United States, suggest that some of our findings may be prone to a type 2 error. Finally, it is possible that a reduction in cesarean delivery rates may be accompanied by an increase in complications, such as chorioamnionitis, hemorrhage, lacerations, and hypoxic ischemic encephalopathy. Differences in the way outcomes were defined between studies limited our ability to pool results. Future studies of doula support should include these safety outcomes and use standardized definitions of pregnancy outcomes.

While doula support improves pregnancy outcomes overall, several studies suggest that increased access to doula support in under-resourced settings could significantly improve pregnancy outcomes.^15,18,36 Further research is needed to explore whether community and/or culturally congruent doula support may be an effective strategy to promote equity in obstetric outcomes for historically marginalized groups that have the highest risk of adverse pregnancy outcomes.^37,38 High-quality studies of doula support, especially those focusing on implementation science and cost-effectiveness, are needed to guide health policy and state Medicaid programs. Furthermore, a longitudinal, life course perspective would be helpful in better understanding both the short- and long-term potential effects of this intervention on maternal, neonatal, and childhood outcomes.³⁹ In conclusion, our findings update the literature and provide additional support for intrapartum doula support as a promising, evidence-based strategy to reduce the risk of cesarean delivery.