Doula support: moderate-certainty links to fewer preterm births and caesareans

Design

Systematic review with GRADE assessment of 12 randomised trials and 18 non-randomised studies

Population

US-based studies of doula support in pregnancy, birth and postpartum versus standard care

Primary outcome

Maternal, infant and partner outcomes, including preterm birth and caesarean delivery

Effect

Moderate certainty of lower preterm birth and caesarean rates; low certainty for most other outcomes; no clear effect on hypertensive disorders

A review for the US evidence base identified 12 randomised trials and 18 non-randomised studies comparing doula support with standard maternity care. Only one study was at low risk of bias, ten at moderate and nineteen at high.

With moderate certainty, doula support was associated with lower preterm birth and caesarean rates, better birth experience and a higher chance of attending the postpartum visit. With low certainty it was associated with better prenatal mood, more spontaneous vaginal birth and greater breastfeeding initiation. It was probably not associated with lower rates of hypertensive disorders, readmissions or neonatal intensive care admission.

In studies made up entirely of people at risk of disparities, four of five reported some benefit. The review could not say what type or intensity of support works best. All included studies were based in the United States, so applicability to Indian labour wards is uncertain.

• Moderate-certainty association with fewer preterm births and caesarean deliveries.
• Better birth experience and higher postpartum visit attendance were also linked to doula support.
• No clear link to fewer hypertensive disorders, readmissions or neonatal intensive care admissions.
• Most included studies were at high risk of bias, and all were set in the United States.
• Where continuous labour companionship is possible, it is a low-risk addition to usual care.

Why it matters

Support in labour is a cheap intervention whose effect on mode of delivery is now graded rather than anecdotal.

Don't overread it

Most of the evidence is observational or at high risk of bias, and it is entirely from the United States.

The statistics, in plain English

'Moderate certainty' on the GRADE scale means the true effect is probably close to the estimate but could differ meaningfully. 'Low certainty' means it may well be different. With 19 of 30 studies at high risk of bias, even the favourable associations could shrink in better trials. Heterogeneity across outcomes means results varied between studies, so a pooled direction is more reliable than any single figure.

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