Doula

Continuous support in labor before the word doula

A 2025 systematic review of intrapartum doula support notes that continuous support during labor is not a new idea. It cites an anthropological study of 150 cultures in which a family member or friend stayed with the mother during delivery in all but one. The same review says the concept of doula support gained traction in the United States in the 1960s and that research on its effects first appeared in a 1980 New England Journal of Medicine trial.

The 2017 Cochrane review of continuous support begins from a similar point, stating that women have historically been attended and supported by other women during labor, and that in hospitals continuous support has often become the exception rather than the routine.

The word and its adoption

An encyclopedia entry on the anthropologist Dana Raphael says she used the word doula in her doctoral dissertation, completed in 1966, for a woman who supports a pregnant woman through childbirth, and that the dissertation was published in 1973 as The Tender Gift: Breastfeeding. The entry says the word comes from a Greek term meaning woman servant. Other sources give different dates for Raphael's first use, and this page relies on the one entry opened.

A 1980 trial in Guatemala by Sosa, Kennell, Klaus and colleagues used the word doula in its abstract for a supportive lay woman who stayed with first-time mothers during labor. That is the earliest controlled study of a doula found for this page.

Professional organizations

DONA International states that it was founded in 1992 as Doulas of North America by Annie Kennedy, John Kennell, Marshall Klaus, Phyllis Klaus and Penny Simkin, and that it adopted its current name in summer 2004. It also says that dictionaries adopted the word doula in 2003 and 2004. These are the organization's own statements about its history. CAPPA, a second certifying body, appears on this page for its published scope and training standards, and its founding date was not verified.

Doula, birth doula and postpartum doula

Different bodies use somewhat different definitions. A 2026 systematic review defines doulas as trained or skilled individuals who offer educational, physical or emotional support during pregnancy, delivery or postpartum, and calls them nonclinical. A 2025 meta-analysis describes support that may be used antepartum, intrapartum or postpartum. DONA certifies birth doulas and postpartum doulas separately, and CAPPA certifies labor doulas and, separately, postpartum doulas.

Doulas and other continuous support providers

The Cochrane review separates continuous support by who provides it: a staff member of the facility, a person who is not on staff and not part of the woman's social network and is present solely to give support, for example a doula, or a person chosen from family and friends. Findings for continuous support in general therefore cannot be read as findings about doulas alone.

Other terms appear in the literature. The 2025 meta-analysis searched for synonyms including labor coach, companionship support, maternity care assistant and traditional birth attendant, and included only studies of professional doulas with training in childbirth support.

Related Machipedia pages

This page is a member of the Machipedia family page Birth Support, which is not repeated here. Related pages cover Midwifery, Childbirth Preparation, Hypnobirthing, Prenatal Massage and Postpartum Confinement Practices. A CAPPA course description states that completing its labor doula training does not qualify a person to act as a midwife or midwifery assistant, so the doula role and the midwifery profession are distinct.

What doulas are described as doing

A qualitative evidence synthesis of 51 studies, mostly from high-income countries and mostly describing women's views, found that labor companions gave four kinds of support: informational, advocacy, practical and emotional. Practical support included encouraging movement, massage and holding a hand. Emotional support included praise, reassurance and a continuous physical presence. Women described doulas as often meeting them before the birth to build rapport and manage expectations.

A review of doula programs in the United States says services can include home visits during pregnancy, continuous support at home in early labor, home visits after the birth to support recovery and parenting, and phone or text contact throughout. Hours of contact vary by program.

Birth and postpartum doula roles

CAPPA describes labor doulas as skilled support persons who act as consultants and resources, not clinicians, providing emotional, physical and informational support, non-medical comfort techniques and referrals to healthcare professionals when clinical needs arise. DONA describes postpartum doulas as supporting families in the weeks and months after birth. CAPPA says its postpartum doulas help with newborn care, infant feeding support and household tasks.

Community-based and hospital-based models

Community-based doulas are described as providing nonclinical perinatal support and often coming from the same communities as the families they serve. A mixed-methods evaluation of one Washington State program reported more than 1,800 families served between 2016 and 2022, 14,672 home visits, direct funds and tangible items such as diapers, and program staff accounts of barriers including burnout and power asymmetries in birth settings.

In a 2026 systematic review of United States studies, more than half of the interventions had doulas affiliated with a hospital or health system and none explicitly used private, independently operating doulas. Almost a quarter used the label community doulas, with definitions that varied widely, and home births were absent from the evidence.

Why people seek doula support

In the qualitative synthesis, women who wanted a companion described needing someone compassionate and trustworthy, and described companionship as helping them have a positive birth experience. Women without a companion could perceive that as a negative experience. Foreign-born women in high-income settings were reported, with low confidence, to appreciate community-based doulas for culturally competent care.

A qualitative study of 28 veterans, 7 doulas and 2 maternity care coordinators in a pilot community-based doula program reported that previous negative birth experiences motivated veterans to want doula care, and that veterans described doulas as helping them advocate for themselves. This is interview data from a small pilot and does not measure clinical outcomes.

Policy and equity framing

Doula care has been proposed as a way to reduce racial and economic disparities in maternal and infant health. A scoping review of 53 reports on Medicaid reimbursement for doula care found that a central policy consideration was partnership with doulas and doula advocates, and that most reports were published in 2021 or 2022. A separate scoping review of 100 United States program studies noted that the outcomes studied were predominantly clinical although doulas are not clinical providers.

Cochrane review of continuous support

The 2017 Cochrane review included 27 randomized trials, 26 of them with usable data from 15,858 women in 17 countries; none were in low-income settings. Compared with usual care, women with continuous support were more likely to have a spontaneous vaginal birth (average risk ratio 1.08, 95% confidence interval 1.04 to 1.12) and less likely to have a cesarean birth (0.75, 0.64 to 0.88) or to report negative feelings about childbirth (0.69, 0.59 to 0.79). Labors were shorter by an average of 0.69 hours.

Most key findings were graded low-quality because no study clearly blinded women or staff. Subgroup analyses, which the authors called exploratory, suggested the largest cesarean reductions when the provider was in a doula role and where epidural analgesia was not routine. The review reported no evidence of harms from continuous support, and no conclusions could be drawn for low-income settings.

Doula-specific reviews and meta-analyses

A 2025 meta-analysis of intrapartum doula support included 8 randomized trials (2,497 women) and 10 observational studies. In the randomized trials, cesarean rates were 17.5 percent with a doula and 23.6 percent with standard care (pooled risk ratio 0.71, 0.53 to 0.95), with substantial heterogeneity and a statistical signal of possible publication bias. In the four trials conducted in the United States the estimate was the same but the interval included no difference (0.47 to 1.06). Low five-minute Apgar scores did not differ.

A 2026 systematic review of United States studies (12 randomized trials and 18 nonrandomized studies) rated one study at low risk of bias, 10 at moderate and 19 at high. It reported moderate-certainty evidence of an association between doula support and lower preterm birth and cesarean rates, better birth experience and higher postpartum visit attendance, and low-certainty evidence for several other outcomes. For cesarean birth, removing high-risk-of-bias randomized trials left an imprecise estimate whose interval spanned no difference.

The same review found low-certainty evidence that doula support may not be associated with fewer hypertensive disorders of pregnancy, maternal readmissions or neonatal intensive care admissions. It found no evidence on the timing of support and very limited evidence on doula characteristics.

Postpartum and breastfeeding research

A 2025 systematic review of 32 studies on doula support and breastfeeding found doula support associated with improved breastfeeding outcomes overall, with mixed findings on duration and exclusivity. Most studies involved populations experiencing marginalization, and doulas reported needing more breastfeeding education in their training.

A 2012 pilot randomized trial recruited 39 mothers with depressive symptoms to a postpartum doula, peer telephone support or a control group. It tested feasibility and was not designed to show an effect on depression. Mothers were more satisfied with doulas than with telephone support, and the doula group had a higher proportion of women with prior depression at the start.

Limits of the evidence base

Most studies cannot blind participants or staff, outcomes vary in definition, and observational comparisons may be affected by who chooses or can obtain a doula. The 2025 meta-analysis notes that its randomized samples may not be representative and that a lower cesarean rate could in principle be accompanied by other complications, so future studies should report safety outcomes such as infection, hemorrhage and lacerations.

A scoping review of doula support and birthing people of color (25 articles) described low reported use of doula services and mixed findings on effectiveness, and noted that few studies were designed to assess intervention effects.

Implementation concerns

The qualitative synthesis found that some providers resisted or were not trained in working with lay companions, which could lead to conflict, and that lay companions were often not integrated into antenatal care. It also found that most programs tested in the effectiveness review did not address the features women described as important in companionship.

The case study of two compensation approaches at a San Francisco community doula network reported that flat-fee contractor pay was seen by doulas and leaders as inadequate for the time worked, and that hourly employment with benefits brought greater financial security. This concerns doula working conditions and not client outcomes.

Community programs and cost estimates

The Washington State evaluation reported preterm birth ranging from 4 percent to 9 percent across programs and more than 94 percent of participants breastfeeding at birth. The summary describes program outcome data and does not describe a comparison group, so these figures do not show an effect of the program.

A scoping review of United States doula programs found that some studies associate doula care with improved clinical outcomes but that the evidence is limited by small samples, study methods and conflicting conclusions. Where cost-effectiveness has been estimated, it largely relies on savings from averted cesarean births, preterm births and neonatal intensive care admissions.

Scope of practice and care boundaries

DONA's standards state that they apply to emotional, physical and informational support only, that a DONA doula does not perform clinical or medical tasks such as checking blood pressure, temperature or fetal heart tones, vaginal examinations or postpartum clinical care, and will not diagnose or treat in any modality. CAPPA states that labor doulas do not diagnose, perform clinical procedures, interpret diagnoses or results, prescribe or treat, make decisions for the client, speak for the family or attend intentionally unassisted births.

These statements describe the standards of two certifying bodies. Doulas are not required by these sources to hold a medical qualification, and conditions such as bleeding, severe pain, reduced fetal movement or other urgent concerns during pregnancy or after birth need assessment by a qualified clinician. A doula is described as a support person alongside, and not instead of, midwives, physicians and nurses.

Reported harms and unknowns

The Cochrane review found no evidence of harms of continuous labor support, and the 2025 meta-analysis found no increase in low Apgar scores, but the latter notes that its included studies did not consistently measure complications that could accompany fewer cesarean births. Adverse-event reporting in doula trials is therefore limited, and the absence of reported harm is not proof that none occurred.

Possible non-clinical concerns include conflict between a lay support person and clinical staff, which the qualitative synthesis describes, and cost where doula care is not covered. The Medicaid scoping review describes variation in reimbursement and access across states.

Training, certification and standards

DONA International certification for birth doulas requires a DONA-approved workshop of 16 to 24 hours, an 8-hour childbirth education course and a 3-hour lactation course (which some trainers bundle), required reading, and continuous in-person labor support for three births with different clients totaling at least 15 hours. No medical background is required, and the packet must be submitted within three years of the workshop. DONA postpartum doula certification requires a workshop of 27 or more hours and support for at least three families, a minimum of 36 hours in total.

CAPPA labor doula certification involves an 18-hour course, a scope of practice pretest with a 100 percent pass mark, required reading, at least three births with parent and healthcare provider evaluations, a multiple-choice exam and an essay exam, and recertification every three years. Requirements differ between certifying bodies and over time, and no statutory training standard was reviewed for this page.