The Role of Doula Support in Reducing Cesarean Delivery Rates

By Ahizechukwu C. Eke, MD, PhD, MPH

Synopsis: Professional intrapartum doula support is associated with a clinically meaningful reduction in cesarean deliveries and operative vaginal births without adverse effects on neonatal Apgar scores. Although heterogeneity and possible publication bias temper certainty, the consistency of benefit across randomized controlled trials and high-quality observational studies supports doulas as a promising and focused strategy to improve intrapartum outcomes.

Source: Dias Y, Achebe NE, Doering MM, et al. Intrapartum doula support and cesarean delivery rates: A systematic review and meta-analysis. Obstet Gynecol. 2025;146(1):73-84.

Over the past several decades, cesarean delivery has become increasingly common in the United States, now representing a substantial proportion of all births.^1,2 Although the procedure is essential in many clinical situations, its rising use has drawn concern because higher cesarean rates at the population level are linked to downstream maternal complications, including abnormal placentation in future pregnancies, surgical morbidity, and increasing healthcare costs.^1,2 These concerns are amplified by persistent structural disparities. For example, racially and ethnically minoritized groups, including American Indian/Alaska Native, Asian, Black, and Latina women continue to experience disproportionately high cesarean delivery rates even when clinical risk profiles are similar to those of white women.^3-5 Efforts to curb unnecessary cesarean deliveries through traditional approaches, such as updated labor management guidelines, provider education, and medicolegal clarification, have produced only incremental change, underscoring the need for additional strategies that address both clinical and structural contributors to the high cesarean delivery rates.

Within this landscape, the integration of professional doulas during labor has gained attention as a complementary, relationship-centered approach to intrapartum care.⁶ Doulas offer continuous emotional reassurance, physical comfort techniques, and informational guidance that extend beyond the scope of traditional clinical care.^7,8 Their engagement often begins prenatally and continues through the labor course, with some models incorporating postpartum follow-up. Randomized controlled trials (RCTs) and observational studies suggest that such continuous nonclinical support can enhance physiologic labor, decrease reliance on pharmacologic pain management, and improve the overall birth experience for women.⁹ Importantly, community-based doula models have demonstrated potential benefits for populations historically underserved within maternity care systems, raising interest in doulas as a mechanism to reduce cesarean delivery rates.¹⁰ Despite growing evidence, doula-supported births remain relatively uncommon nationwide because of challenges in reimbursement, integration within hospital-based care teams, and variability in programmatic infrastructure.

Dias and colleagues conducted a contemporary systematic review and meta-analysis to more precisely estimate the association between intrapartum doula support and mode of delivery, focusing exclusively on professional doulas providing in-person support during labor and birth.¹¹ Data sources included Ovid Medline, Embase, Scopus, Cochrane Central, and ClinicalTrials.gov from inception through Aug. 30, 2024. The authors included English-language RCTs and observational studies that compared intrapartum professional doula support with standard care. Non-original research, case reports, studies without comparison groups, or those evaluating non-doula companions (e.g., family members or clinicians) were excluded.

The primary outcome was cesarean delivery. Secondary outcomes included operative vaginal delivery, low five-minute Apgar score (less than 7), and the use of regional anesthesia. At least two studies with comparable definitions were required to pool any outcome. Study quality was assessed using the Downs and Black checklist, with studies at or above the 75th percentile (score ≥ 23/28) considered high quality. Random-effects meta-analysis (restricted maximum likelihood) was used to pool relative risks (RRs) and 95% confidence intervals (CIs), with heterogeneity assessed using the Cochran Q and I² statistics. Heterogeneity was considered meaningful at P < 0.10 or I² > 30%. Publication bias was evaluated via funnel plots and Harbord tests.

Eighteen studies involving 367,662 women met inclusion criteria: eight RCTs (n = 2,497; 50.9% allocated to doula support) and 10 observational studies (n = 365,165; 1.7% exposed to doula care). In the primary analysis restricted to RCTs, intrapartum doula support was associated with a statistically significant reduction in cesarean delivery compared with standard care (17.5% vs. 23.6%; pooled RR, 0.71; 95% CI, 0.53, 0.95). Similar effect estimates were observed when analyses were restricted to high-quality trials (15.8% vs. 22.0%; pooled RR, 0.70; 95% CI, 0.50, 0.99) and when observational studies were pooled (22.1% vs. 31.8%; pooled RR, 0.77; 95% CI, 0.66, 0.90). When the analysis was limited to RCTs conducted in the United States, the point estimate for cesarean delivery reduction (pooled RR, 0.71) was similar, but 95% CIs crossed unity (0.47, 1.06).

For secondary outcomes, doula support in RCTs was associated with a significantly lower rate of operative vaginal delivery (7.9% vs. 13.2%; pooled RR, 0.64; 95% CI, 0.44, 0.94). No consistent association was observed between doula support and low five-minute Apgar scores. Pooled RRs across study designs were imprecise and generally compatible with no difference. Regional anesthesia use did not differ significantly in RCTs, although observational studies suggested lower rates among doula-supported patients (pooled RR, 0.71; 95% CI, 0.56, 0.91).

Commentary

This study showed that continuous, non-clinical labor support by doulas meaningfully improves birth outcomes. From a mechanistic standpoint, doulas may reduce cesarean delivery risk through multiple, interacting pathways, including enhancing patients’ sense of understanding of labor processes, supporting physiologic coping strategies that reduce fear and stress, helping patients communicate preferences and concerns, and, at times, buffering implicit bias or communication breakdowns within busy labor units. The observed concurrent reduction in operative vaginal deliveries suggests that doula support may broadly promote spontaneous vaginal birth rather than simply shifting the distribution of assisted deliveries. Importantly, these benefits were achieved without evidence of harm in neonatal Apgar scores, although more robust reporting of perinatal safety outcomes is needed.

The implications of this work are particularly salient. Community-based, culturally concordant doula programs, such as those serving Somali immigrants in Minnesota, migrant communities in Sweden, and low-income neighborhoods in Brooklyn, NY, have reported reduced need for analgesia, preterm birth, low birth weight, and cesarean delivery among historically marginalized groups of pregnant women.^12-14 These findings, coupled with well-documented racial and ethnic disparities in cesarean delivery rates, raise the possibility that strategic investment in doula care could serve as a structural intervention to reduce differences in birth outcomes among pregnant women. However, coverage and access remain limited. Even in states that reimburse doulas through Medicaid, programs often face low reimbursement rates, administrative hurdles for credentialing and billing, and challenges integrating doulas into hospital workflows.

Dias et al appropriately highlight several limitations that temper overinterpretation.¹¹ Considerable heterogeneity across studies spanning populations, health systems, doula training and scope, and baseline cesarean delivery rates likely contributes to wide confidence intervals and inconsistent secondary outcomes. Selection bias is an ongoing concern in observational cohorts, where those who seek or are offered doula care may differ systematically from those who do not. Even RCTs may enroll relatively motivated and resourced participants, limiting generalizability. Many included trials are older, with obstetric practice patterns that differ substantially from contemporary labor management guidelines. Finally, the apparent signal of small-study effects suggests that negative or null trials may be underreported, which could overstate benefit.

Despite these caveats, the totality of evidence positions intrapartum doula support as one of the few interventions that consistently lowers cesarean delivery risk while aligning with patient-centered care and cost-effectiveness goals. Implementation science is urgently needed now to move from efficacy to real-world impact. Priority areas include defining core doula competencies and minimum training standards, evaluating sustainable reimbursement models (including global fees and value-based payment) for Medicaid and commercial payers, integrating doulas into interprofessional team structures without medicalizing their role, and standardizing outcome measures, especially safety endpoints, to facilitate cross-study comparisons. Prospective, adequately powered RCTs in diverse U.S. settings, with stratified analyses by race, ethnicity, and insurance status, will be critical to determining whether doula support can narrow, rather than widen, existing structural differences in maternal and neonatal outcomes.

In conclusion, this systematic review and meta-analysis provides evidence that professional intrapartum doula support reduces cesarean delivery and operative vaginal birth rates without compromising fetal, neonatal, and infant health. In the context of rising cesarean delivery rates, persistent racial and structural disparities, and mounting calls for respectful, person-centered maternity care, doulas represent a promising, evidence-informed strategy that merits thoughtful integration into standard obstetric practice. According to guidance from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, continuous labor support, including support provided by doulas, is one of the most effective strategies to reduce cesarean delivery rates.¹⁵

Ahizechukwu C. Eke, MD, PhD, MPH, is Associate Professor in Maternal Fetal Medicine, Division of Maternal Fetal Medicine, Department of Gynecology & Obstetrics, Johns Hopkins University School of Medicine, Baltimore.

References

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