Doula support: fewer caesareans and preterm births at moderate certainty

Design

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

Population

Pregnant and postpartum people in the United States

Primary outcome

Maternal, infant and partner outcomes across pregnancy, birth and postpartum

Effect

Lower preterm birth and caesarean rates, moderate certainty; 19 of 30 studies at high risk of bias

A systematic review of 12 randomised trials and 18 non-randomised studies, all from the United States, compared doula support with standard maternity care across pregnancy, birth and the postpartum period.

At moderate certainty, doula support was associated with lower rates of preterm birth and caesarean delivery, better birth experience and more attendance at postpartum visits. Lower-certainty evidence suggested less epidural use, shorter labour and more breastfeeding initiation. There was no clear effect on hypertensive disorders, maternal readmission or neonatal unit admission.

Nineteen of the 30 studies carried high risk of bias and outcomes were heterogeneous. The finding fits long-standing evidence that continuous support in labour helps, and argues for allowing a trained companion throughout labour.

• Offer every woman a continuous labour companion of her choice, whether a trained doula or a family member.
• Where a unit restricts companions in labour, review whether that policy still holds.
• Expect less effect from doulas on hypertensive disease or neonatal admission; the benefit is in the birth process and follow-up.
• Use doula or companion programmes to improve postpartum visit attendance in women at risk of missing them.

Why it matters

Support in labour is a low-cost intervention with a consistent signal on caesarean rates, which many units still restrict.

Don't overread it

All studies were from the United States and most had high risk of bias; the size of the effect elsewhere is uncertain.

The statistics, in plain English

The review graded its certainty using GRADE rather than giving a single pooled number for every outcome. Moderate certainty means the true effect is probably close to the estimate; low certainty means it may be substantially different.

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