OBs denying doula access: Where’s the SCIENCE!!!1!?

Can someone show me again the SCIENCE!!!1! behind denying access to a doula during maternity care?

Here are a few excerpts of papers I found, mixed in type (quantitative research, qualitative research, meta-analysis, review), on doula care. Emphases are mine.

The effect of a supportive companion on perinatal problems, length of labor, and mother-infant interaction.
Sosa R et al
N Engl J Med. 1980 Sep 11;303(11):597-600.

We studied the effects of a supportive lay woman (“doula”) on the length of labor and on mother-infant interaction after delivery in healthy Guatemalan primigravid women. Initial assignment of mothers to the experimental (doula) or control group was random, but controls showed a higher rate (P less than 0.001) of subsequent perinatal problems (e.g. cesarean section and meconium staining). It was necessary to admit 103 mothers to the control group and 33 to the experimental group to obtain 20 in each group with uncomplicated deliveries. In the final sample, the length of time from admission to delivery was shorter in the experimental group (8.8 vs. 19.3 hours, P less than 0.001).

Continuous emotional support during labor in a US hospital. A randomized controlled trial.
Kennell J et al
JAMA. 1991 May 1;265(17):2197-201.

The continuous presence of a supportive companion (doula) during labor and delivery in two studies in Guatemala shortened labor and reduced the need for cesarean section and other interventions. In a US hospital with modern obstetric practices, 412 healthy nulliparous women in labor were randomly assigned to a supported group (n = 212) that received the continuous support of a doula or an observed group (n = 200) that was monitored by an inconspicuous observer. Two hundred four women were assigned to a control group after delivery. Continuous labor support significantly reduced the rate of cesarean section deliveries (supported group, 8%; observed group, 13%; and control group, 18%) and forceps deliveries. Epidural anesthesia for spontaneous vaginal deliveries varied across the three groups (supported group, 7.8%; observed group, 22.6%; and control group, 55.3%). Oxytocin use, duration of labor, prolonged infant hospitalization, and maternal fever followed a similar pattern. The beneficial effects of labor support underscore the need for a review of current obstetric practices.

[Lots more below the cut…]

Lower epidural anesthesia use associated with labor support by student nurse doulas: implications for intrapartal nursing practice.
Van Zandt SE et al
Complement Ther Clin Pract. 2005 Aug;11(3):153-60.

Doulas, trained to support laboring mothers, are associated with shorter labors and fewer medical interventions. Data from a convenience sample of 89 vaginal births attended between 1999 and 2002 were analyzed. Analysis showed an association of lower epidural use with increased complementary doula interventions (.62 OR, P=.003) and an association of higher epidural use with longer labors (1.22 OR, P=.004).

Doula birth support for incarcerated pregnant women.
Schroeder C, Bell J.
Public Health Nurs. 2005 Jan-Feb;22(1):53-8.

The objective of this study was to provide trained labor support (doulas) to pregnant women in jail. […] Surveys administered to providers and officers demonstrated high satisfaction with the program. Qualitative interviews with 14 women indicated unanimous support for the services and documented women’s major concerns. Findings support offering doula services to all pregnant women in custody and expanding doula services to include early and comprehensive intervention coordinated by nurses.

The nature and management of labor pain: part I. Nonpharmacologic pain relief.
Leeman L et al
Am Fam Physician. 2003 Sep 15;68(6):1109-12.

Nonpharmacologic methods of pain relief such as labor support, intradermal water blocks, and warm water baths are effective techniques for management of labor pain. An increased availability of these methods can provide effective alternatives for women in labor.

A randomized control trial of continuous support in labor by a lay doula.
Campbell DA et al
J Obstet Gynecol Neonatal Nurs. 2006 Jul-Aug;35(4):456-64.

OBJECTIVE: To compare labor outcomes in women accompanied by an additional support person (doula group) with outcomes in women who did not have this additional support person (control group). DESIGN: Randomized controlled trial. SETTING: A women’s ambulatory care center at a tertiary perinatal care hospital in New Jersey. PATIENTS/PARTICIPANTS: Six hundred nulliparous women carrying a singleton pregnancy who had a low-risk pregnancy at the time of enrollment and were able to identify a female friend or family member willing to act as their lay doula.
RESULTS: Significantly shorter length of labor in the doula group, greater cervical dilation at the time of epidural anesthesia, and higher Apgar scores at both 1 and 5 minutes. Differences did not reach statistical significance in type of analgesia/anesthesia or cesarean delivery despite a trend toward lower cesarean delivery rates in the doula group.
CONCLUSION: Providing low-income pregnant women with the option to choose a female friend who has received lay doula training and will act as doula during labor, along with other family members, shortens the labor process.

Factors influencing duration of breast feeding among low-income women.
Barron SP et al
J Am Diet Assoc. 1988 Dec;88(12):1557-61.

Forty low-income breast feeding primiparous women were interviewed to determine whether family member and peer attitudes toward breast feeding and available postpartum support were associated with continued or early termination of breast feeding. Mean breast feeding duration equalled 20.5 weeks (range, 1 to 52 weeks). When an outside source of assistance (a doula) was available during the first 2 weeks postpartum, mean duration was 23.4 weeks compared with 12.3 weeks when a doula was unavailable (p less than .05).

“Doula care, early breastfeeding outcomes, and breastfeeding status at 6 weeks postpartum among low-income primiparae.”
Nommsen-Rivers LA et al
J Obstet Gynecol Neonatal Nurs. 2009 Mar-Apr;38(2):157-73.

OBJECTIVE: To examine associations between doula care, early breastfeeding outcomes, and breastfeeding duration.
DESIGN: Prospective cohort.

CONCLUSIONS: Doula care was associated with improved childbirth outcomes and timely onset of lactogenesis. Both directly and as mediated by timely onset of lactogenesis, doula care was also associated with higher breastfeeding prevalence at 6 weeks.

Step 1: Offers All Birthing Mothers Unrestricted Access to Birth Companions, Labor Support, Professional Midwifery Care: The Coalition for Improving Maternity Services
Leslie MS, Storton S.
J Perinat Educ. 2007 Winter;16(Suppl 1):10S-19S.

The first step of the Ten Steps of Mother-Friendly Care insures that women have access to a wide variety of support in labor and during the pregnancy and postpartum periods: unrestricted access to birth companions of their choice, including family and friends; unrestricted access to continuous emotional and physical support from a skilled woman such as a doula; and access to midwifery care.

A randomized controlled trial of continuous labor support for middle-class couples: effect on cesarean delivery rates.
McGrath SK, Kennell JH.
Birth. 2008 Jun;35(2):92-7.

METHODS: Nulliparous women in the third trimester of an uncomplicated pregnancy were enrolled at childbirth education classes in Cleveland, Ohio, from 1988 through 1992. Of the 686 prenatal women recruited, 420 met enrollment criteria and completed the intervention. For the 224 women randomly assigned to the experimental group, a doula arrived shortly after hospital admission and remained throughout labor and delivery. Doula support included close physical proximity, touch, and eye contact with the laboring woman, and teaching, reassurance, and encouragement of the woman and her male partner.
RESULTS: The doula group had a significantly lower cesarean delivery rate than the control group (13.4% vs 25.0%, p = 0.002), and fewer women in the doula group received epidural analgesia (64.7% vs 76.0%, p = 0.008). Among women with induced labor, those supported by a doula had a lower rate of cesarean delivery than those in the control group (12.5% vs 58.8%, p = 0.007). On questionnaires the day after delivery, 100 percent of couples with doula support rated their experience with the doula positively.

Women’s Perceptions of Their Doula Support.
Koumouitzes-Douvia J, Carr CA.
J Perinat Educ. 2006 Fall;15(4):34-40.

The pilot qualitative study presented in this article explored women’s perceptions of the doula support they received in the perinatal period, with the aim of describing details of their experiences. Study participants were 12 women who had hospital births with the support of a certified doula. In-depth interviews were conducted postpartum with all 12 participants. Interview topics included specific categories and aspects of doula support and whether participants would use and/or recommend doulas in the future. Transcripts were analyzed using content analysis. Emerging themes included support for husbands, tailored approaches, reassurance and encouragement, fulfillment of the women’s desire for support from an experienced woman, and praise for the doula. The findings suggest that the doulas were beneficial in multiple areas for their clients.

A hospital-based doula program and childbirth outcomes in an urban, multicultural setting.
Mottl-Santiago J et al
Matern Child Health J. 2008 May;12(3):372-7. Epub 2007 Jul 3.Click here to read

RESULTS: For the whole cohort, women with doula support had significantly higher rates of breastfeeding intent and early initiation. Subgroup analysis showed that having doula support was significantly related to: (a) higher rates of breastfeeding intent and early initiation rates for all women regardless of parity or provider with the exception of multiparous women with physician providers; (b) lower rates of cesarean deliveries for primiparous women with midwife providers.
CONCLUSION: A hospital-based doula support program is strongly related to improved breastfeeding outcomes in an urban, multicultural setting.

Alternative Strategy to Decrease Cesarean Section: Support by Doulas During Labor.
Trueba G et al
J Perinat Educ. 2000 Spring;9(2):8-13

From March 1997 to February 1998, a group of 100 pregnant women were studied. These women were at term, engaged in an active phase of labor, exhibited 3 cm. or more cervical dilatation, were nuliparous, had no previous uterine incision, and possessed adequate pelvises. The group was randomly divided into two subgroups comprising 50 women, each: The first subgroup had the support of a childbirth educator trained as a doula, while the second subgroup did not have doula support. […]
Results confirmed that support by doulas during labor was associated with a significant reduction in cesarean birth and pitocin administration. There was a trend toward shorter labors and less use of epidurals. The results of this study showed, as in other trials measuring the impact of a doula’s presence during labor and birth, that doula support during labor is associated with positive outcomes that have physical, emotional, and economic implications.

Continuous female companionship during childbirth: a crucial resource in times of stress or calm.
Pascali-Bonaro D, Kroeger M.
J Midwifery Womens Health. 2004 Jul-Aug;49(4 Suppl 1):19-27.

Continuous support by a lay woman during labor and delivery facilitates birth, enhances the mother’s memory of the experience, strengthens mother-infant bonding, increases breastfeeding success, and significantly reduces many forms of medical intervention, including cesarean delivery and the use of analgesia, anesthesia, vacuum extraction, and forceps. The contribution of doula care has become increasingly available in industrial countries and is beginning to be adopted in hospitals in underdeveloped countries. Research continues to demonstrate the far-reaching value of supportive companionship as a corollary to professional health care during birth. Mothers who are at risk because of medical or social factors and those delivering in situations of stress, including disasters, can benefit greatly from labor support.

Doula–a new concept in obstetrics
Thomassen P et al
Lakartidningen. 2003 Dec 18;100(51-52):4268-71.

We wanted to study the effect of extra emotional support in the form of a non-professional woman (doula) before and during delivery. About 200 primiparae were invited to participate in a prospective study which intended to assess differences in delivery outcome between women with and without a doula. Fifty-four declined to participate, 55 had a delivery with doula and 46 were controls. Lower rate of emergency caesarean sections in the doula-group was noted. The parents as well as the staff, became to regard the doula as a valuable support during delivery.

A comparison of intermittent and continuous support during labor: a meta-analysis.
Scott KD, Berkowitz G, Klaus M.
Am J Obstet Gynecol. 1999 May;180(5):1054-9.

Our goal was to contrast the influence of intermittent and continuous support provided by doulas during labor and delivery on 5 childbirth outcomes. Data were aggregated across 11 clinical trials by means of meta-analytic techniques. Continuous support, when compared with no doula support, was significantly associated with shorter labors (weighted mean difference -1.64 hours, 95% confidence interval -2.3 to -.96) and decreased need for the use of any analgesia (odds ratio.64, 95% confidence interval.49 to.85), oxytocin (odds ratio.29, 95% confidence interval.20 to.40), forceps (odds ratio.43, 95% confidence interval.28 to.65), and cesarean sections (odds ratio.49, 95% confidence interval.37 to.65). Intermittent support was not significantly associated with any of the outcomes.

Effects of psychosocial support during labour and childbirth on breastfeeding, medical interventions, and mothers’ wellbeing in a Mexican public hospital: a randomised clinical trial.
Langer A et al
Br J Obstet Gynaecol. 1998 Oct;105(10):1056-63.

OBJECT: To evaluate the effects of psychosocial support during labour, delivery and the immediate postpartum period provided by a female companion (doula). DESIGN: The effects of the intervention were assessed by means of a randomised clinical trial. Social support by a doula was provided to women in the intervention group, while women in the control arm received routine care. […]
CONCLUSIONS: Psychosocial support by doulas had a positive effect on breastfeeding and duration of labour. It had a more limited impact on medical interventions, perhaps because of the strict routine in hospital procedures, the cultural background of the women, the short duration of the intervention, and the profile of the doulas. It is important to include psychosocial support as a component of breastfeeding promotion strategies.

The doula: an essential ingredient of childbirth rediscovered.
Klaus MH, Kennell JH.
Acta Paediatr. 1997 Oct;86(10):1034-6.

Eleven randomized control trials examined whether additional support by a trained lay person (called a doula), student midwife or midwife, who provides continuous support consisting of praise, encouragement, reassurance, comfort measures, physical contact and explanations about progress during labor, will affect obstetrical and neonatal outcomes. The women were healthy primigravidas at term. Meta-analysis of these studies showed a reduction in the duration of labor, the use of medications for pain relief, operative vaginal delivery, and in many studies a reduction in caesarian deliveries. At 6 weeks after delivery in one study a greater proportion of doula-supported women were breastfeeding, reported greater self-esteem, less depression, a higher regard for their babies and their ability to care for them compared to the control mothers. Observations during labor showed that fathers remained farther away from mothers than doulas, talked and touched less. When the doula was present with the couple during labor the father offered more personal support. The father-to-be’ s presence during labor and delivery is important to the mother and father, but it is the presence of the doula that results in significant benefits in outcome.

Continuous labor support from labor attendant for primiparous women: a meta-analysis.
Zhang J et al
Obstet Gynecol. 1996 Oct;88(4 Pt 2):739-44.

DATA EXTRACTION AND SYNTHESIS: Meta-analysis of four studies conducted among young, low-income, primiparous women who gave birth on a busy labor floor in the absence of a companion suggested that continuous labor support by a labor attendant shortens the duration of labor by 2.8 hours (95% confidence interval [CI] 2.2-3.4), doubles spontaneous vaginal birth (relative risk [RR] 2.01, 95% CI 1.5-2.7) and halves the frequency of oxytocin use (RR 0.44, 95% CI 0.4-0.7), forceps use (RR 0.46, 95% CI 0.3-0.7), and cesarean delivery rate (RR 0.54, 95% CI 0.4-0.7). Women with labor support also reported higher satisfaction and a better postpartum course.
CONCLUSION: Labor support may have important positive effects on obstetric outcomes among young, disadvantaged women.

Social support in labor–a selective review.
Chalmers B, Wolman W.
J Psychosom Obstet Gynaecol. 1993 Mar;14(1):1-15.

Support during labor has been offered by a variety of different people, including fathers, professional medical staff, trained labor coaches and monitrices, untrained lay supporters and family and friends. A comparison of the various findings shows that support given by trained or lay untrained female supporters, who are not necessarily known to the laboring woman, yields the most extensive, methodologically sound, and consistently positive effects on obstetric and psychosocial outcomes. Although trained labor coaches have been shown to exert a positive effect on outcome, the results of doula support are the most impressive when both methodology and outcome effects are considered. […] Support from professional medical staff is rare, but when given, has, in some cases, had a positive effect. These findings are important for the field, since the use of lay supporters constitutes a low-cost preventive intervention.

So show me again the “other side” of this argument. Show me the published papers demonstrating that doulas are damaging to women’s health. Show me the preponderance of scienterrific evidence obstetricians are using to inform their decisions to deny one-to-one lay labour care workers to women. I’d like to weigh the evidence for myself.

Categories: gender & feminism, Science

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12 replies

  1. Thanks for this great literature review which I will forward to my doula from my second daughter’s birth (though she’s been known to read here) and to pregnant friends.
    Almost a shame to add anecdote to data, but having a doula there with me through contractions really did act as pain relief.

  2. Yes, I found this to be incredibly infuriating. I was going to do research on only doulas before I decided to expand the project to more labor interventions. One of the main reasons I decided not to do another RCT with doulas is because the body of evidence is already SO complete and convincing, it would have been redundant.
    So, now my research is going to be to determine why obstetricians don’t use evidence based medicine during labor and delivery. it was the logical next step, considering the evidence support for doulas and the lack of support for their use. This Aspen clinic you link to is exhibit A why this research needs to be done.
    My favorite source for my research (and rants) is Berghella’s Evidence Based Labor and Delivery Management. Only two practices were given an evidence support grade of “A”: use of a doula and upright positions for the second stage. I am guessing this Aspen Clinic doesn’t favor or encourage either of these practices, but probably uses plenty of the practices given C, D or I (inconclusive evidence support) ratings, such as continuous external fetal monitoring, denying oral nutrition, fetal weight estimates, episiotomy and the like.

  3. “So show me again the “other side” of this argument.”
    The other side of the arugment being, of course, that you and your doula are getting in the way of me putting empirical evidence into practice as your obstetrician. Don’t mind me while I ignore current research to do this. You wouldn’t want to harm your baby, right? Plus, you’re not qualified to judge me and neither is your doula.
    Does that sum up the logic?
    .-= Jill–Unnecesarean´s last blog ..Women Describe Walking, Moving and Changing Positions in Labor =-.

  4. You’ve confirmed the point that the OB banning the doulas was making. Having a doula makes the women think she is a human being who is an active participant in the birthing process rather than a container from which the foetus is being delivered. And we can’t have that!

  5. I used Lamaze natural childbirth in a Manhattan, NYC hospital in 1970. Spouse and I had been to classes. My labor was very slow. I actually had time to wash and dry my hair before going to the hospital, after my water broke. My spouse (first husband) was my partner in the labor room, and delivery room. I was given oxytocin. I lost all awareness of time when I was near 9centimeters cervix dilated.
    The contractions were strong. I recently told my present spouse, of my demanding to know why the obstetrician had his whole darn (not the word I used) hand in my uterus. I said I didn’t think I could take any more contractions and considered pain killers. The OBGYN took my spouse into the hall and asked how I’d feel the next day, if I stopped natural childbirth? He said I’d feel bad. They came back in. (I had no concept of time at that point.) The OBGYN told me that
    I only needed 10 min. as I was 9 centimeters (cervix) dilated and I said “OK” and
    continued. The baby’s head “crowned” and the head’s pressure deadened the nerves anyway. Watching the delivery was a peak experience of my life!
    I had left my contact lenses in, so I could see, figuring my spouse would tell the doctor if a cesarian was necessary. The doctor was really angry the next day that I hadn’t told him. Are they still doing episotomies (sic)? I closed my eyes as I was being cut a bit- from the sound of the crunch. Local anesthetic and some demerol near the end. The baby was fine. Large and “late” re due date. I couldn’t wait to get out of the hospital (weekend nurse discouraged breast feeding!), and some jerk wanted to give the baby a blood change, not being able to read my dr’s penmanship about my blood type. Luckily, I had a blood donor card with proof of my blood type being same as baby’s = my OBGYN overrode the hospital pediatrician and baby was not given blood change. Coming home and going through the first few months (as in very little sleep) and later, with no support for families, made me a feminist – actually on day 2. And I immediately escalated my
    peace “no war” feelings.

  6. Correction: OBGYN’s hand was in my vagina, feeling my uterus during the contractions (that looked like a loaf of bread in my abdomen), not in my uterus.

  7. I’m currently reading Robbie Davis-Floyd’s book “Birth as an American Rite of Passage”. She makes the point that: “By making the naturally transformative process of birth into a cultural rite of passage for the mother, a society can take advantage of her extreme openness to ensure that she will be imprinted with its most basic notions about the relationship of the natural to the cultural world as these two worlds meet in the act of birth. She will then indeed receive the knowledge she has been seeking – in the form of an enactment of the belief and value system of the society that she must help to perpetuate”. (p.40)
    If you look at it from that perspective, a doula is a threat; not just to the doctors and their authority, but to the whole patriarchal and technocratic structure of society.
    If a woman births without technology, with another woman supporting her, then the knowledge that is imparted to her in this rite of passage is that women are strong and women support each other, instead of that women’s bodies are flawed and dangerous, and women must be rescued by men.
    ETA: and that nature is only there to be subdued by technology.

  8. Evidence and surgeons simply don’t equate, relate, have any connection. Surgeons are just there to be the embodiment of misogyny and commerce.
    Meanwhile the anti-homebirth legislation in Australia is before the Senate today with massive gaps and total bullshit about to be delivered to us as law.
    A paranoid person may begin to feel that women are oppressed.

  9. Lauredhel, the science is clear enough for anyone who cares to be objective about this issue.

    The OBs are wearing scrubs, are they not? And they have lots of Very Important letters after their names. Many of them, I have it on good authority, also have penises.

    Doulas, on the other hand, have none of these things. Clearly, then, they are not Sciencey.

    So, in conclusion, um, ipse dixit! (That is Latin, so it is extra sciencey).

  10. I think the true worry by this doctor’s office is that the Doula could be a expert witness who ALSO witnesses any mistakes by the doctor’s staff during the birth!
    We live in NC and I was very lucky; both hospitals we looked at delivery in encourage doulas– one even has volunteer doulas available. (Duke, UNC). However, when I asked my insurance company about paying I was told that was too, “cutting edge.” Most of the research showing how doulas save money, lives, pain, etc. that I found was over a decade old. What is so cutting edge about 10 year old science?!?
    The baby’s grandparents couldn’t understand why we wanted a doula– when we were born one nurse stayed with you the whole time. So not true now!


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