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There’s been some buzz about doulas in the news lately, including that a major health insurance company is adding coverage for doula care because, as the title to the article proclaims: “Doulas can improve health outcomes for women and babies.” Because of that, I thought this would be a good time to turn my lens on doulas. This post, then, will discuss the doula research, explain how they help during labor, answer common questions about their care, and, in the “Takeaway” section, offer tips on choosing the right one for you.

What Does the Research Say?

As advertised, doulas improve outcomes.

To begin with the research finds that having continuous one-on-one physical and emotional support regardless of who provides it reduces the odds of having a negative birth experience. A systematic review (a study pooling data from multiple studies on a particular topic) found that compared with usual nursing care, continuous labor support, whether it be from a doula, a health professional, or a member of the laborer’s social circle, reduced the percentage who rated their birth experience negatively from 18 percent to 12 percent.³ This is no small benefit because memories of a negative birth experience persist for a lifetime and rating the birth experience negatively is associated with developing childbirth-related posttraumatic stress disorder (PTSD).^{2, 5, 19}

In addition, doulas reduce cesareans and instrumental vaginal deliveries. A different systematic review found that in trials where participants were assigned by chance to doula care versus usual nursing care, a strategy that helps ensure the two groups are similar in ways that could affect outcomes, having a doula reduced cesareans from 24 percent to 18 percent and instrumental deliveries from 13 percent to 8 percent.⁶ A study of doula versus no doula in a disadvantaged population found that having a doula increased VBACs (22 percent vs. 13 percent), although it had no effect on cesareans overall or on cesareans at low-risk (one, head-down baby at term) first births.¹⁴

As for babies, an analysis of Medicaid claims data found that doulas reduced preterm births (9 percent vs. 12 percent) as well as cesarean rates (24 percent vs. 44 percent),⁹ and the study in the disadvantaged population also reported a reduction in preterm births (7 percent vs. 11 percent).¹⁴

Here’s the caveat with those findings, though: promoting doulas to improve maternal and newborn outcomes buries the lede. Doulas help, but the power and responsibility to decrease cesareans and improve the birth experience lies with hospitals and obstetricians. Nor can having a doula in labor reduce preterm births. That lies with social and economic policies. Obtaining a doula merely indicates other factors that could affect preterm birth rates.  Doulas aren’t the Solution; they’re the canaries in the mine.

What Are the Benefits of Having a Doula?

A doula ensures you have one-on-one continuous emotional and physical support and your intimate partner has emotional support. A doula will be familiar with hospital environments and how things work within them, which can be of enormous help not just to you but also to your partner and anyone else you’ve chosen to be with you during the birth. A doula is someone on your side, someone who can help you work through decisions and get the information you need to make them, assistance that can become crucial if you find yourself attended by medical staff who aren’t in your corner, and unfortunately, that’s a real possibility.

Q&A on Doulas

Why aren’t the nurses plus my intimate partner enough?

It could happen, but it isn’t likely.

Work sampling studies conducted in the 1990s and early 2000s looked at how L&D nurses spent their time and found they spent almost none of it providing physical or emotional supportive care^{10, 11, 16}—and that was before it became common to monitor incoming patient data from a central nursing station, so we have little reason to think things have gotten better and every reason to think they may have gotten worse.

Furthermore, nurses typically don’t think of supportive care in the same light doulas do. One of the work sampling studies reported much greater percentages of nurses engaging in supportive care than the others.¹⁷ What was different? Investigators built their checklist from a nursing-profession document and from asking L&D nurses what items to include. The second most commonly provided support measure was “ensuring adequate urinary elimination,” which could mean offering a bedpan, urinary catheterization, or emptying a urine collection bag. None of the supportive care activities that the other work sampling studies included, such as reassuring touch, massage, keeping company with the laboring woman or birthing person, or suggesting labor coping strategies, were even on the checklist.

Even when specifically tasked with providing one-on-one continuous support, hospital staff don’t measure up. A systematic review looked at effect on cesarean rates in trials assigning participants to continuous support by hospital staff versus usual nursing care and unlike the case with doula care, found no effect on cesarean rates.³

Why isn’t my intimate partner (and other family or friends I’m having with me) enough?

No one can replace your loved ones, but doulas bring expertise and knowledge that fills in potential gaps.

Labor support largely amounts to “mothering the mother,” which may pressure men, at least, into a role for which they may be unsuited.^{4, 15} Even when men are ready and willing, they lack experience with providing supportive care in labor, especially if this is their first birth, and when sympathizing or giving advice, they lack the credibility of someone with first-hand experience of living in a female body.

A female intimate partner may not present the credibility problem, but male or female, either may lack experience and both are working in an unfamiliar and almost certainly intimidating environment. What’s more, both have needs and concerns that will likely go unmet. Without a doula, intimate partners must be all in all to their loved one for many hours during an experience that is as stressful and demanding on them in its way, as it is on the person in labor.⁸

Having additional family members and friends solves some of those problems, but it doesn’t necessarily solve all of them. They may be carrying baggage from their own birth experiences or have expectations of you. As with your intimate partner, they may also have their own emotional needs or concerns during the labor. They, too, aren’t likely to have experience with being with someone in labor and how to be helpful to them, and they won’t know the hospital system.

How does having a doula affect my intimate partner’s or my family’s and friends’ role?

You may be concerned that a doula will take over from your partner or your family and friends, but the opposite is true. A doula enhances, not replaces, their care. A doula’s guidance and support takes the pressure off your partner and others and ensures they have their own needs met while helping you meet yours. Specifically, having a doula allows your intimate partner to choose their level of involvement, allows the ability to take breaks, provides a model for how to care for you, and helps reduce stress and anxiety by providing your partner information and supportive care. The same is true for additional family or friends plus the doula can act as team leader.

Would I still benefit from having a doula if I’m planning an epidural?

I think you would—provided your doula is on the same page about your choice. Here are some reasons why:

• A doula can help you with labor at home, which may prevent going to the hospital prematurely. Hospital admission too early contributes to increased use of medical interventions, including cesarean surgery.
• A doula can help you delay an epidural until active labor. That can avoid some of its adverse effects such as epidural-related fever leading to keeping the baby in the nursery, drawing blood samples to rule out infection, and even starting precautionary IV antibiotics.
• The anesthesiologist may not be available when you want the epidural.
• Sometimes epidurals don’t take or leave an area unnumbed.
• And finally, epidurals may relieve pain, but you still need emotional support, and the tricks of the trade doulas know may help you avoid some of an epidural’s adverse effects.

Last, but not least, you may find that, with good support, labor isn’t as hard as you thought it would be, and you can manage without an epidural, which means you don’t run the risk of experiencing its adverse effects.

Would I still benefit from having a doula if I’m planning a home or birth center birth?

Supportive care is built in to births at home or in a freestanding birth center (a birth center that isn’t part of a hospital). That being said, here are some ways a doula can be helpful at a home or birth center birth:

• Your midwife’s focus will be on your wellbeing and that of your baby. Doulas are supportive care specialists and complement the midwife’s role.
• Doulas can help with support in early labor before your midwife arrives or you leave for the birth center.
• They can help with household chores, preparing food, and cleanup at home births.
• They can be the point person for caring for your intimate partner or other relatives or friends, and they can help with childcare if a child (or children) will be present.
• Your midwife may not be able to accompany you should transfer to the hospital become necessary, in which case, a doula can provide ongoing support to you, your intimate partner, and any other support companions.

Your Takeaway

By now, you’ve gotten that while having a doula can be of great value, they aren’t the main players in your avoiding an avoidable cesarean or negative birth experience, and they can’t prevent your having a preterm birth. If you want to learn how to determine whether a hospital or hospital-based doctors or midwives provide care supportive of physiologic birth and a positive birth experience, see the “Takeaway” section of this article. Better yet, if you are at low risk for complications, consider planning a home or birth center birth. You can find out more about these options here. Here, though, I want to pull out two questions specific to doulas I think are vital to ask your care providers and on your hospital tour:

• What is your (or the nursing staff’s) opinion of doulas?
• Does the hospital place any restrictions on doulas or have agreements they must sign in order to participate in my care?

A negative opinion of doulas is a huge red flag, and the requirement to sign an agreement as a condition of being allowed to be with you is an even bigger one. Doubtless many nurses welcome doulas as providing complementary care to what they are able to do; however, it’s a fact that nurses and doctors have generally been hostile to doula care from its beginnings to the present day.^{7, 13, 18} This is primarily because hospitals are top-down social structures: The doctor at the top gives orders; the nurse in the middle sees that they are implemented; the patient, who is at the bottom of the social structure, complies.¹² From the hospital’s perspective, doulas are outside of this structure, which makes them loose cannons, potentially instigating patient resistance to complying. The hospital’s solution, as these examples from hospital agreements illustrate,¹ is to bring doulas under control:

I will support the medical interventions and explanations given by the clinical team.

Hospital will respect the role of Doula providing the services to Patient; provided, Hospital shall have the ultimate authority for all patient care decisions.

That’s a problem for you because, first of all, contrary to the assertion in the second quote, it isn’t the Hospital’s right to make decisions about your care; it’s yours. And as the first quote makes clear, the hospital admits of only two possibilities: either you’re under staff’s control, or you’re under your doula’s control, neither of which acknowledges your agency to make decisions, which, again, is your right.

In light of this, if your care providers or the nursing staff at the hospital you have chosen have a negative opinion of doulas or the hospital has doulas sign agreements of this kind, my advice is to change your care if at all possible. If it isn’t, well, at least you’re forewarned and can brainstorm with your doula how you will navigate around this obstacle during labor.

Okay. On with finding a doula. I see your interview questions as falling into two categories: choosing the right doula for you and the business aspects.

Choosing the Right Doula for You

The conversation itself, apart from the answers, should give you a good sense of who this doula is and whether they’re right for you. You want someone who’s a good fit for both you and your partner, someone around whom you can be yourself completely without any need to self-censor or please them, and someone you feel you can trust in a vulnerable situation. Trust your instincts as to whether that will be true of this doula.

• What is your background, training, and experience relevant to doing labor support? Are you certified by a doula training program? I would lean strongly toward hiring a certified doula. Certification doesn’t guarantee you someone wonderful or that they’re the right fit for you, but it indicates that the doula has acquired a body of knowledge and set of skills.
• What do you see as your strengths?
• How do you see your role at the birth?
• How do you feel about . . . ? Fill in the blank with anything on which you have an opinion or which is part of your plans such as an epidural, prayer during the labor, the presence of your other children, home birth, etc.
• Do you work with any particular hospitals, doctors, or midwives? For the reason stated in the introduction to this section, you don’t want a doula who is employed by the hospital. An employee answers to their employer, and you want that employer to be you. As for working with certain practitioners or in certain hospitals, this can be positive in that this person will be known and respected, or it may be a disadvantage in that it may create a conflict of interest.
• Do you have any limitations on where you will go or which caregivers you work with? If the doula doesn’t attend births in certain hospitals or take clients who have particular care providers, find out why. It may be useful information if your choice is one of them.

As for the business aspects, many doulas have contracts. You’ll want to review their contract, of course, and here are some aspects of care you’ll want to know about:

• What is in your package of care? Does the doula make prenatal visits? What is included in those visits? At what point do they come to be with you during labor? Do they make postpartum visits? How many and what is included?
• How many clients do you take a month? Do you have anyone else due close to my due date? This you will tell you something about the doula’s availability, although you get no guarantees.
• What are your back-up arrangements? May I meet or speak with your back-up? It’s always possible that your doula will be unable to attend the birth or have to leave during the labor. It’s also a good idea to know something about the back-up person to make sure they are agreeable to you and so that they won’t be a complete stranger should they end up attending you.
• What is your policy for unusually long labors? Does the doula charge extra? Do they transfer care to someone new?
• What is your fee, and what is the payment structure? Doulas can be a bargain in terms of what they can do for you, but that doesn’t mean they come cheap. Depending on where you live, a labor doula can cost from $500 to as much as $4000.^{20, 21} Some health insurance companies have begun covering doula care as has Medicaid in a number of states.⁹ Here are a couple of articles with useful information on paying for doula care, including creative strategies if it will be financially burdensome: How Much Do Doulas Cost? and Are Doulas Covered by Insurance?
• What is your refund policy?
• Will you provide references? If it’s possible to contact this person or people, ask what they liked about this doula. Their answer may help you decide whether this doula is a good match for you too.

References

1. Alicia & Meredith. Hospital “Doula Agreements” and You. In; Nov. 25, 2025.
2. Ayers S, Bond R, Bertullies S, et al. The aetiology of post-traumatic stress following childbirth: a meta-analysis and theoretical framework. Psychol Med 2016;46(6):1121-34.
3. Bohren MA, Hofmeyr GJ, Sakala C, et al. Continuous support for women during childbirth. Cochrane Database Syst Rev 2017;7:CD003766.
4. Chapman L. Searching: expectant fathers’ experiences during labor and birth. J Perinat Neonatal Nurs 1991;4(4):21-9.
5. Dekel S, Stuebe C, Dishy G. Childbirth Induced Posttraumatic Stress Syndrome: A Systematic Review of Prevalence and Risk Factors. Front Psychol 2017;8:560.
6. 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.
7. Eftekhary S, Klein MC, Xu SY. The life of a Canadian doula: successes, confusion, and conflict. J Obstet Gynaecol Can 2010;32(7):642-9.
8. Etheridge J, Slade P. “Nothing’s actually happened to me.”: the experiences of fathers who found childbirth traumatic. BMC Pregnancy Childbirth 2017;17(1):80.
9. Falconi AM, Ramirez L, Cobb R, et al. Role of Doulas in Improving Maternal Health and Health Equity Among Medicaid Enrollees, 2014‒2023. Am J Public Health 2024;114(11):1275-85.
10. Gagnon AJ, Waghorn K. Supportive care by maternity nurses: a work sampling study in an intrapartum unit. Birth 1996;23(1):1-6.
11. Gale J, Fothergill-Bourbonnais F, Chamberlain M. Measuring nursing support during childbirth. MCN Am J Matern Child Nurs 2001;26(5):264-71.
12. Goer H. Supportive Care in Labor: Mothering the Mother Versus Serving the Doctor. In: Goer H., Romano A., eds. Optimal Care in Childbirth: The Case for a Physiologic Approach. Seattle, WA: Classic Day Publishing; 2012.
13. Lantz PM, Low LK, Varkey S, et al. Doulas as childbirth paraprofessionals: results from a national survey. Womens Health Issues 2005;15(3):109-16.
14. Lemon LS, Quinn B, Young M, et al. Quantifying the association between doula care and maternal and neonatal outcomes. Am J Obstet Gynecol 2025;232(4):387 e1- e43.
15. McGrath SK, Kennell JH. A randomized controlled trial of continuous labor support for middle-class couples: effect on cesarean delivery rates. Birth 2008;35(2):92-7.
16. McNiven P, Hodnett E, O’Brien-Pallas LL. Supporting women in labor: a work sampling study of the activities of labor and delivery nurses. Birth 1992;19(1):3-8; discussion -9.
17. Miltner RS. More than support: nursing interventions provided to women in labor. J Obstet Gynecol Neonatal Nurs 2002;31(6):753-61.
18. Papagni K, Buckner E. Doula Support and Attitudes of Intrapartum Nurses: A Qualitative Study from the Patient’s Perspective. J Perinat Educ 2006;15(1):11-8.
19. Simkin P. Just another day in a woman’s life? Women’s long-term perceptions of their first birth experience. Part I. Birth 1991;18(4):203-10.
20. How Much Do Doulas Cost? Parents, Aug 22, 2024. (Accessed Aug 25, 2024, at https://www.parents.com/pregnancy/giving-birth/doula/how-much-do-doulas-cost/.)
21. Are Doulas Covered by Insurance? What to Expect, Mar 5, 2025. (Accessed Mar 6, 2025, at https://www.whattoexpect.com/pregnancy/labor-and-delivery/doulas-covered-by-insurance.)