Doula Care for Middle Class Women with Male Partners Substantially Lowers Cesarean Rate

McGrath, S. K., & Kennell, J. H. (2008). A randomized controlled trial of continuous labor support for middle-class couples: Effect on cesarean delivery rates. Birth, 35(2), 92-97. [Abstract]

Summary: In this randomized, controlled trial, healthy, middle-class pregnant women expecting their first child were assigned to have continuous support from a trained and certified doula (n = 224) or to usual care (n = 196). The doula group had support from their male partners as well as a doula, while the usual care group were accompanied by partners but did not have the additional support of a doula. The women were primarily Caucasian (78%), married (88%), and educated (57% had college degrees). All women in both groups attended childbirth education classes in the greater Cleveland area between 1988 and 1992. Researchers collected data about labor and birth outcomes from the medical chart. In addition, couples who had doula care in labor were asked to complete questionnaires before hospital discharge and approximately six weeks after giving birth. Eighty-eight percent of mothers returned both questionnaires. Among fathers, 81% returned the first questionnaire while 76% returned the questionnaire sent at six weeks.

The doula group was significantly less likely to give birth by cesarean section than the control group (13% versus 25%, an excess of 12%). Doulas had an even more marked effect on the likelihood of cesarean when labor was induced. Ten of the 17 women in the control group who were induced gave birth by cesarean section compared with only 2 of the 16 women induced in the doula group, a highly significant finding (excess 47%). Doula-supported women were also less likely to have epidural analgesia, although most women in both groups had epidurals (65% in the doula group versus 76% in the control group, excess 12%). On the first postpartum questionnaire (administered before hospital discharge), all women and all of the male partners rated having a doula as "very positive" (93%) or "positive" (7%). All but two respondents rated having a doula as very positive or positive at six weeks postpartum.

Significance for Normal Birth: A large body of literature, including two well-designed systematic reviews, provides overwhelming evidence for the benefits of continuous support in labor. However, previous studies have varied greatly in aspects of trial quality, population studied, and presence of other support people, and many of the trials have been conducted in countries with maternity care systems unlike that in the United States .
This variation raises the question of whether results apply to the population who typically attend childbirth preparation classes. Moreover, in an era when male partners are usually present at birth, we have lacked evidence as to whether doulas provide additional benefit.

This new study provides compelling evidence that, even when accompanied by their male partners, middle class first-time mothers benefit immensely from professional doula care. Specifically, even with epidural use and induction, they may markedly decrease their chances of having cesarean surgery. Moreover, these benefits are achieved with no loss in satisfaction by their male partners.