There is sufficient evidence that doula care positively impacts health and social outcomes.
This assessment was made possible through support from Elevance Health. HealthBegins retains full editorial independence, and the content herein reflects its sole views and conclusions.
The findings below synthesize the results of the studies on doula care across three domains of measurement:
Maternal health encompasses a person’s health during pregnancy, birth, and postpartum[1]. Out of 3.7 million births in the United States (U.S.) in 2021[2], 41% were covered by Medicaid[3]. Medicaid covered over half of births among Black and Hispanic individuals[4]. Medicaid also covers a large portion of individuals who are under age 25[5].
Adequate prenatal and postpartum care is integral to maternal health. In 2022, 74.9% of individuals who are birthing received early and adequate prenatal care[6] while the percentage of birthing people receiving no prenatal care increased to 2.3% in 2023[7]. Postpartum visit rates vary from 24.9% to 96.5%[8]. In addition to varying postpartum visit rates, the content and quality of care provided vary widely based on insurance, rural versus urban setting, and race/ethnicity[9]. Additionally, between 12%-17% of the gender-diverse individuals assigned female at birth have been pregnant at least once[10],[11],.
The U.S. has the highest rate of maternal mortality (death within 42 days from the end of pregnancy from any cause related to the pregnancy or its management[12]), when compared to other high-income countries[13]. In 2022, the maternal mortality rate was 22.3 deaths per 100,000 live births[14]. Between 2017-2019, 80% of pregnancy-related deaths were deemed preventable[15]. The maternal mortality rate for non-Hispanic Black women is 2.6 times the rate for non-Hispanic White women[16]. The top three causes of pregnancy-related deaths for Hispanic/Latino and White birthing people are mental health conditions, hemorrhage, and a tie between cardiac/coronary conditions and infection. For Black women, the top three causes of pregnancy-related deaths are cardiac/coronary conditions, cardiomyopathy, and thrombotic embolism[17]. Overall, mental health conditions are a leading underlying cause of all pregnancy-related deaths, accounting for 23% of such deaths (e.g., deaths by suicide and overdose/poisoning related to substance use disorder)[18]. Death by suicide accounts for about 20% of postpartum deaths[19].
Pregnant and postpartum individuals also experience a 16% increase in the incidence of homicide compared to those who are not pregnant or postpartum. Homicide is the leading cause of all-cause maternal mortality during pregnancy or within 42 days of the end of pregnancy, accounting for more than two times the other leading causes of death during this period[20].
Maternal morbidity includes any health problems that cause death from pregnancy, both short- and long-term, including cardiovascular disease, infection, bleeding, high blood pressure, and blood clots[21]. One estimate found that roughly 29% of pregnancies include some maternal complication or morbidity, with about 11% of pregnancies including a life-threatening complication[22]. Pregnant Black individuals experience higher rates of maternal morbidity caused by eclampsia/preeclampsia and venous thromboembolism or pulmonary embolism, while pregnant Asian/Pacific Islander individuals experience higher rates of severe postpartum hemorrhage[23].
Maternal Health and Social Needs
Pregnancy and postpartum can exacerbate health-related social needs and compound their negative effects. A pregnant individual’s access to screening for medical risk factors is affected by social and structural drivers of health, such as access to basic needs like transportation and childcare. However, even after such risks are identified, people who are pregnant may not be able to access resources to address those needs due to the same social and structural drivers of health that lead to poor health in the first place[24].
While emphasis is placed on the pregnancy and birth stages of maternal health, physical and mental health concerns remain significant in parenthood and are exacerbated by social needs. According to 2023 data, 48% of parents say that their stress is overwhelming most days compared to 26% among other adults[25]. Parental stressors include financial strain, economic instability, poverty, time demands, children’s health/safety concerns, parental isolation and loneliness, technology and social media, cultural pressures, and worry about children’s futures. Another parental stressor is the cost of childcare. The cost of childcare is inaccessible for many families as the cost is equivalent to 8%-19.3% of the median family income per year for each child in paid care[26].
A doula is a “trained professional who provides continuous physical, emotional, and informational support to their client before, during, and shortly after childbirth to help them achieve the healthiest most satisfying experience possible[27].” A focus group of racially diverse low-income people who had recently given birth found that doulas promote a positive birth experience by supporting agency, personal security, connectedness, respect, and knowledge of the person who is pregnant. The researchers hypothesize that by providing social support and improving health literacy, doulas may be reducing the impact of social risk factors and racism (including obstetric racism)[28],[29],. While spaces dedicated to reproductive health are generally heteronormative, doula services specific to the LGBTQ+ community can be supportive in navigating processes and systems that are often not conducive to providing inclusive and affirming care[30]. Additionally, most available research does not reflect the experiences of gender-diverse people of color who are pregnant as most studies have focused on White populations.
Implementation of doula programs have been hampered by low awareness of doulas (one study found lower awareness among Black birthing people than White birthing people)[31], hospital policies that impede doulas, and mixed success at collaboration with clinical providers. Low reimbursement rates, stress of being on-call, and burnout impact workforce development and retention[32]. Future doula programs should consider these potential challenges.
As of April 2024, California, Maryland, Massachusetts, Michigan, Minnesota, Nevada, New Jersey, New York, Oklahoma, Oregon, Rhode Island, Virginia, and Washington, DC all include coverage and reimbursement for doulas as a Medicaid benefit. Washington, Utah, Colorado, South Dakota, Illinois, Ohio, Pennsylvania, Tennessee, Louisiana, Delaware, Connecticut, and New Hampshire are all in the process of implementing a doula Medicaid benefit[33]. Some states with existing doula benefits are increasing reimbursement rates to increase access to doula services. Coverage typically includes a set number of pre and postpartum visits as well as attendance at the delivery[34]. The 2022 White House Blueprint for Addressing The Maternal Health Crisis included increasing reimbursement for doulas as a key strategy and supported states in developing doula Medicaid benefits. As of March 2023, only one state, Rhode Island, mandates private health insurance coverage of doula care but multiple other states have bills under consideration[35].
Nulliparous women carrying a singleton pregnancy and with a low-risk pregnancy at the time of enrollment, and who were able to identify a female friend or family member willing to act as their lay doula.
Accompaniment of women by an additional support person (lay doula). A certified doula who was a research assistant for the project taught the lay doulas traditional doula supportive techniques in two 2-hour sessions.
Randomized control trial. 600 women were enrolled.
Healthcare Cost, Utilization & Value: No statistical differences in the type of analgesia/anesthesia or cesarean delivery despite a trend toward lower cesarean delivery rates in the doula group.
Health: The doula group had significantly shorter labor, greater cervical dilation at the time of epidural anesthesia, and higher Apgar scores at both one and five minutes.
Nulliparous women carrying a singleton pregnancy and with a low-risk pregnancy at the time of enrollment, and who were able to identify a female friend or family member willing to act as their lay doula.
Accompaniment of women by an additional support person (lay doula). The lay doula was taught traditional doula supportive techniques in two 2-hour sessions by a certified doula who was a research assistant.
Randomized controlled trial. Surveys of 494 birthing individuals (n=229 used doulas, n=265 without doulas).
Health: Doula-supported people were more likely to report positive prenatal expectations about childbirth, positive perceptions of their infants, support from others, and self-worth. Doula-supported mothers were also more likely to have breastfed and to have been very satisfied with the care they received at the hospital.
Black mothers under the age of 22 with low incomes.
Provision of doula home visitors trained as childbirth educators and lactation counselors. Doulas provided home visits from pregnancy through three months postpartum, and support during childbirth. Control-group mothers received usual prenatal care.
Randomized trial. The study enrolled 248 individuals. Data were obtained from medical records and maternal interviews at birth and four months postpartum.
Health: Intent-to-treat analyses showed that doula-group mothers attempted breastfeeding at a higher rate than control-group mothers (64% vs 50%) and were more likely to breastfeed longer than six weeks (29% vs 17%), although few mothers still breastfed at four-months. The intervention also impacted mothers’ cereal/solid food introduction: fewer doula-group mothers introduced complementary foods before six weeks of age (6% vs 18%), while more waited until at least four months (21% vs 13%) compared with control-group mothers.
Medicaid recipients who are pregnant in California, Florida, and a Northeastern state.
Doula care.
Retrospective cohort. Propensity score matching and logistic regression models were used to calculate associations between selected health outcomes and doula care. The analysis included 298 pairs of women matched on age, race/ethnicity, state, socioeconomic status, and hospital type (teaching or non-teaching).
Healthcare Cost, Utilization & Value: Women who received doula care had 52.9% lower odds of cesarean delivery. Doulas who provided care with a clinical team that included a midwife most consistently showed a reduction in odds of cesarean delivery, regardless of the trimester when doula care was received.
Health: Women who received doula care had 57.5% lower odds of postpartum depression/postpartum anxiety. Women who received doula care during labor and birth, but not necessarily during pregnancy, showed a 64.7% reduction in odds of postpartum anxiety/postpartum depression.
Expectant mothers.
Provision of doula support during hospital-based labor.
Randomized controlled trial. There were 314 individuals (n=149 with doulas, n=165 with usual care). Data was obtained from medical charts, study intake forms, and phone interviews conducted four-to-six weeks postpartum
Healthcare Cost, Utilization & Value: The two groups did not differ significantly in rates of cesarean, vaginal, forceps, vacuum delivery, or oxytocin administration.
Health: Women who had doulas had significantly less epidural use (54.4% vs 66.1%), were significantly more likely to rate the birth experience as good (82.5% vs 67.4%), feel they coped very well with labor (46.8% vs 28.3%), and felt labor had a very positive effect on their feelings as women (58.0% vs 43.7%). There was no statistically significant difference in breastfeeding, postpartum depression, or self-esteem measures.
Expectant mothers.
Provision of pre-birth assistance from a certified doula.
Observational study with a comparison group. Comparative analysis of two groups of mothers from the same childbirth education program. The sample consisted of 225 individuals (78% Black; age range 13 to 31 years); 128 used doulas and 97 did not.
Health: Doula-assisted mothers were four times less likely to have a low-birth-weight baby, two times less likely to experience a birth complication involving themselves or their baby, and significantly more likely to initiate breastfeeding.
Families with low incomes receiving doula home visiting services.
Provision of doula home visits. Participants randomized into the doula-home visiting intervention group were assigned a home visitor (called a Family Support Worker or Parent Educator) and a community doula. Participants randomized into the case-managed control group were provided information about case management services in their communities and case management providers were given participants’ contact information.
Randomized controlled trial. The study involved 312 participants (45% Black, 38% Latina/Hispanic) recruited from 2011 to 2015.
Healthcare Cost, Utilization & Value: There were no differences in cesarean delivery, birth weight, prematurity, or postpartum depression.
Health: Women in the intervention group were more likely to attend childbirth-preparation classes (50% vs 10%), less likely to use epidural/pain medication during labor (72% vs 83%) and more likely to initiate breastfeeding (81% vs 74%), although the breastfeeding impact was not sustained over time.
Social: Intervention-group participants were more likely to put infants on their backs to sleep (70% vs 61%) and utilize car seats at three weeks (97% vs 93%).
Pregnant, low-income, diverse women.
Doula support.
Observational study with a comparison group. Comparative analysis of breastfeeding initiation rates for women (n= 1,069) who received doula care to a state-based sample (n= 51,721) of Medicaid-covered women who gave birth in 2009 or 2010 and participated in the Minnesota Pregnancy Risk Assessment Monitoring System (PRAMS) survey.
Health: Women who had doula-supported births had near-universal breastfeeding initiation, 97.9%, compared with 80.8% of the general Medicaid population. Among Black women, 92.7% of those with doula support initiated breastfeeding, compared with 70.3% of the general Medicaid population.
Medicaid recipients in Minneapolis, Minnesota.
Prenatal education and childbirth support from trained doulas.
Observational study with a comparison group. Data from 1,079 Medicaid recipients who received prenatal education and childbirth support from trained doulas with outcomes were compared to a national sample (n=279,008) of similar women.
Healthcare Cost, Utilization & Value: The cesarean rate was significantly lower (22.3%) among doula-supported births than among Medicaid beneficiaries nationally (31.5%). The corresponding preterm birth rates were 6.1% and 7.3%, respectively (however, this did not reach significance). Modeling, based on the assumption that a state could reduce its cesarean rate for Medicaid births to 22.3% by offering birth doula services to beneficiaries, found that annual savings might exceed $2.5 million for up to a quarter of all states.
Medicaid recipients with prenatal access to doula care.
Prenatal access to doula care.
Cost-effectiveness analysis. A mathematical model of the potential cost-effectiveness of Medicaid coverage of doula services was created. Data was collected from two sources: 1) Medicaid-funded, singleton births at hospitals in the West North Central and East North Central U.S. (n=65,147) in the 2012 Nationwide Inpatient Sample, and 2) all Medicaid-funded singleton births (n=1,935) supported by a community-based doula organization in the Upper Midwest from 2010-2014.
Healthcare Cost, Utilization & Value: Women who received doula support had lower preterm and cesarean birth rates than Medicaid beneficiaries regionally (4.7% vs. 6.3%, and 20.4% vs. 34.2%, respectively). After adjustment for covariates, women with doula care had 22% lower odds of preterm birth. Cost-effectiveness analyses indicate potential savings associated with doula support reimbursed at an average of $986, (ranging from $929 to $1,047 across states).
Expectant mothers who received any prenatal care within the University of Pittsburgh Medical Center health system within the cohort of live births at the Magee-Women’s Hospital from January 2021 to December 2022.
Doula care.
Observational study. The sample included 17,831 deliveries, 486 of which received doula care and 17,345 of which did not.
Healthcare Cost, Utilization & Value: For every 100 patients who received doula care, there were 15 to 34 more vaginal births after cesarean (adjusted risk difference, 15.6; 95% confidence interval, 3.8–27.4; adjusted risk difference, 34.2; 95% confidence interval, 0.046–68.0) and five to six more patients who attended a postpartum office visit (adjusted risk difference, 5.4; 95% confidence interval, 1.4–9.5; adjusted risk difference, 6.8; 95% confidence interval, 3.7–9.9) when compared with those who did not receive doula services.
Infants born to patients receiving doula care were 20% more likely to be exclusively breastfed (adjusted risk ratio, 1.22; 95% confidence interval, 1.07–1.38), and doula care was associated with three to four fewer preterm births (adjusted risk difference, −3.8; 95% confidence interval, −6.1 to −1.5; −4.0; 95% confidence interval, −6.2 to −1.8) for every 100 deliveries. Results were consistent regardless of race or insurance. Results were also consistent when doula care was redefined as having at least three prenatal encounters with a doula.
Mothers in California.
Self-reported doula care
Observational study with a comparison group evaluating whether women were more likely to report having received respectful care (high levels of decision making, support and communication during childbirth), if they had a doula. Data was used from the 2018 Listening to Mothers in California survey for 1,977 interviewed women.
Social: There were higher odds of respectful care among women supported by a doula than those without support. The association was largest for non-Hispanic Black women and Asian/Pacific Islander women. Doula support predicted higher odds of respectful care among women with Medi-Cal, but not private insurance.
Individuals in England who had given birth and who had identified vulnerabilities such as social isolation, poverty, poor mental health, domestic violence, recent migration (including two resettled refugees), previous traumatic birth, and an older child with disabilities.
Antenatal and postnatal provision of a doula.
Qualitative. Semi-structured qualitative interviews with 13 individuals who had given birth and 19 doulas with experience supporting disadvantaged mothers during pregnancy.
Social: Doulas believed that their community role was at least as important as their role at the delivery. Their support was highly valued by the vulnerable participant individuals who were pregnant and helped to improve their parenting confidence and skills. The study concluded that volunteer doula support before and after birth can have a positive impact on maternal emotional wellbeing by reducing anxiety, unhappiness, and stress, and increasing self-esteem and self-efficacy.
Expectant mothers.
Provision of labor support by a hospital-based doula program.
Observational study. Retrospective program evaluation using data collected over seven years for a cohort of 11,471 women.
Healthcare Cost, Utilization & Value: Having doula support was significantly related to lower rates of cesarean deliveries for primiparous women with midwife providers.
Health: Having doula support was significantly related to higher rates of breastfeeding intent and early initiation rates for all women regardless of parity or provider except for multiparous women with physician providers.
Nulliparous pregnant individuals insured by publicly funded health plans and with lower-risk pregnancies in an urban safety net hospital.
A community doula program embedded in a safety net hospital.
Pragmatic randomized trial. 367 participants were included in the primary analysis.
Healthcare Cost, Utilization & Value: There was a statistically nonsignificant 12% absolute reduction in cesarean births.
Health: In the intent-to-treat analysis, outcomes were similar between groups. There was a trend toward increased breastfeeding initiation (p=0.08). There was an 11.5% increase in exclusive breastfeeding during delivery hospitalization among non-Hispanic Black participants.
Publicly insured women in central Texas.
Providing people who are pregnant and covered by Texas Medicaid with access to doulas during their pregnancy.
A cost-benefit analysis was conducted using secondary data carried out over a short-term time horizon, taking a public payer perspective. Outcomes of interest were preterm delivery and cesarean delivery. The comparison condition was the current, usual state.
Healthcare Cost, Utilization & Value: Providing people who are pregnant and covered by Texas Medicaid with access to doulas during their pregnancies was cost-beneficial (benefit-to-cost ratio: 1.15) in the base model and 65.7% of the time in probabilistic sensitivity analyses covering a feasible range of parameters. The intervention is most cost-beneficial for Black women. Reimbursing doulas at $869 per client or more yielded costs that were greater than benefits, holding other parameters constant.
Expectant mothers.
The By My Side Birth Support Program was introduced in 2010 by the New York Department of Health and Mental Hygiene’s Healthy Start Brooklyn. It complemented other maternal home-visiting programs by providing doula support during labor and birth, along with prenatal and postpartum visits.
Observational study with a comparison group. Outcomes for the By My Side program were compared to residents overall in the project area by live births.
Healthcare Cost, Utilization & Value: Rates of cesarean birth did not differ significantly (33.5 vs. 36.9%, p = 0.122).
Health: Compared to the project area, program participants had lower rates of preterm birth (6.3 vs. 12.4%, p < 0.001) and low-birth weight (6.5 vs. 11.1%, p = 0.001).
Women and communities of color with low incomes in New York City.
Provision of free birth and postpartum doula services through the Healthy Women Healthy Futures program.
Observational study. Program data (n=364) collected between 2020 and 2021 was used for the analysis. Univariate and multivariable analyses focused on: the method of delivery, preterm birth, low-birth weight birth, breastfeeding, and maternal-infant skin contact. The key exposure variable was total doula hours.
Healthcare Cost, Utilization & Value: Clients who received prenatal doula support had high rates of vaginal delivery (69.1%). The multivariable analysis did not identify an association between the number of doula hours and any of the five outcomes examined.
Health: Descriptively, clients who received prenatal doula support had high rates of breastfeeding in the hospital (90.9%), maternal-infant skin contact (78.2%), and low rates of preterm birth (8.8%) and low-birth weight (7.1% ). However, the multivariable analysis did not identify an association between the number of doula hours and any of the five outcomes examined.
Expectant mothers and their babies.
Provision of continuous, one-to-one intrapartum support, defined as support by other women during labor and birth. Continuous support is defined as “women [who are] cared for and supported by other women during labor and birth and have had someone with them throughout.”
Systematic review. A Cochrane review of 27 trials involving 15,858 individuals.
Healthcare Cost, Utilization & Value: Women who received continuous labor support may be more likely to give birth 'spontaneously,' (i.e. give birth vaginally with neither ventouse nor forceps nor cesarean). In addition, women may be less likely to use pain medications or to have a cesarean birth and may be more likely to be satisfied and have shorter labors. Subgroup analyses suggested that continuous support was most effective at reducing cesarean birth when the provider was present in a doula role, and in settings in which epidural analgesia was not routinely available.
Health: Postpartum depression could be lower in women who were supported in labor, but the authors could not be sure of this due to the studies being difficult to compare (they were in different settings, with different people giving support). The babies of women who received continuous support may be less likely to have low five-minute Apgar scores. The authors did not find any difference in the number of babies admitted to special care, and there was no difference found in whether the babies were breastfed at age eight weeks. No adverse effects of support were identified.
Mothers and babies.
Doula support.
Literature review. 16 studies were analyzed.
Healthcare Cost, Utilization & Value: The analysis reveals a variety of benefits, such as lower rates of C-section and epidural anesthesia associated with doula care and virtually no drawbacks.
Health: Doulas are associated with higher rates of breastfeeding and lower rates of premature birth.
Childbearing women in the United States.
Doula support.
Scoping review. A review of 3,679 article titles and abstracts yielded 42 articles for full-text review; three articles met the final inclusion criteria. One included study focused on intrapartum doula support and two on doula support that extended throughout the perinatal period.
Health: Within the included studies, doula support was associated with decreased rates of intrapartum maternal fever and gestational hypertension; however, it was not associated with decreased rates of gestational diabetes or depression.
Expectant mothers.
Provision of additional support by a doula, student midwife, or midwife providing continuous support during labor.
Systematic review. 11 randomized controlled trials were analyzed.
Healthcare Cost, Utilization & Value: Reduction in operative vaginal delivery, and in many studies a reduction in cesarean deliveries.
Health: Reduction in the duration of labor, and the use of medications for pain relief. At six weeks after delivery in one study, a greater proportion of doula-supported women who were breastfeeding reported greater self-esteem, less depression, higher regard for their babies, and their ability to care for them compared to the controls.
Social: When the doula was present with the couple during labor, the partner offered more personal support based on observations during labor.
Veterans who are pregnant, birthing, and postpartum.
Doula support.
Evidence brief. 41 studies were included.
Healthcare Cost, Utilization & Value: Doula support may be associated with a reduced rate of cesarean births, reduced use of oxytocin or Pitocin, and reduced use of epidurals. Doula support could be associated with reduced labor pain, fewer low birth weight neonates, and fewer NICU admissions, but more well-designed studies with clear adherence to doula intervention are needed to better determine impact. No evidence of harms of doula support or support by layperson companionship during labor were identified.
Health: Doula support may be associated with shorter duration of labor and higher Apgar scores for neonates.
People who are pregnant with low incomes in New York.
Interventions directed at reducing maternal mortality in New York.
Systematic review. Sixteen total studies were included in the review for analysis; of these, one community-based initiative provided doulas to pregnant low-income individuals.
Healthcare Cost, Utilization & Value: No difference in cesarean sections (33.5% compared to 36.9%) compared to program nonparticipants.
Health: Participants of hospital-based programs showed significantly lower rates of preterm birth (6.3% compared to 12.4%) and low birth weight (6.5% compared to 11.1%). Additionally, participants in the program gave positive feedback. The overall review concluded that current hospital-based interventions have not reduced maternal mortality in New York. However, the community-based doula intervention identified did reduce adverse birth outcomes.
Expectant mothers.
Doula support.
Systematic review. 12 randomized clinical trials and three associated meta-analyses from 1986 to 1999 were included.
Healthcare Cost, Utilization & Value: Emotional and physical support from doulas significantly shortens labor and decreases the need for cesarean deliveries, forceps and vacuum extraction, oxytocin augmentation, and analgesia. Doula-supported mothers also rate childbirth as less difficult and painful than do women not supported by a doula.
Social: Eight of the 12 trials report early or late psychosocial benefits of doula support. Early benefits include reductions in state anxiety scores, positive feelings about the birth experience, and increased rates of breastfeeding initiation. Later postpartum benefits include decreased symptoms of depression, improved self-esteem, exclusive breastfeeding, and increased sensitivity of the mother to her child's needs.
Expectant mothers.
Doula support.
Scoping review.
Healthcare Cost, Utilization & Value: Doula guidance in perinatal care was associated with positive delivery outcomes including reduced cesarean sections.
Health: Doula guidance in perinatal care was associated with reduced premature deliveries and length of labor.
Social: The emotional support provided by doulas was seen to reduce anxiety and stress. Doula support, specifically in low-income women, was shown to improve breastfeeding success, with quicker lactogenesis and continued breastfeeding weeks after childbirth.
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[11] The language used in this assessment reflects what is used in the literature (e.g., “women”). While it may accurately reflect the study data, it may not be inclusive of or relevant to the experience of gender-diverse individuals.
[12] World Health Organization. International statistical classification of diseases and related health problems, 10th revision (ICD–10). 2008 ed. Geneva, Switzerland. 2009.
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