Impact of Doulas on Healthy Birth

Outcomes
Kenneth J. Gruber, PhD
Susan H. Cupito, MA
Christina F. Dobson, MEd

ABSTRACT
Birth outcomes of two groups of socially disadvantaged mothers at risk for adverse birth outcomes, one
receiving prebirth assistance from a certified doula and the other representing a sample of birthing mothers
who elected to not work with a doula, were compared. All of the mothers were participants in a prenatal
health and childbirth education program. Expectant mothers matched with a doula had better birth outcomes. Doula-assisted mothers were four times less likely to have a low birth weight (LBW) baby, two times
less likely to experience a birth complication involving themselves or their baby, and significantly more likely
to initiate breastfeeding. Communication with and encouragement from a doula throughout the pregnancy
may have increased the mothers self-efficacy regarding her ability to impact her own pregnancy outcomes.

The Journal of Perinatal Education, 22(1), 4956, http://dx.doi.org/10.1891/1058-1243.22.1.49

Keywords: doula, birth outcome, prenatal health

Modern hospital maternity care practices have

reduced the availability of an attending nurse to remain with a mother during labor. A result of this has
been the loss of having someone at the bedside to offer
continuous support throughout the birthing process
(Papagni & Buckner, 2006). One study found that
new mothers expected their nurse to spend 53% of
her time offering support, but only 6%10% of the
nurses time was actually engaged in labor support
activities (Tumblin & Simkin, 2001). Because many
women during labor are comforted and encouraged
by having someone with them throughout labor
and birth, support persons known as doulas have
become increasingly present. Doulas are trained

Impact of Doulas | Gruber et al.

to provide physical, emotional, and informational

support to women during labor, birth, and in the
immediate postpartum period. With the support of
doulas, many women are able to forego epidurals,
avoid cesarean births, and have less stressful births.
A skilled doula empowers a woman to communicate
her needs and perceptions and actualize her dream
of a healthy, positive birth experience. The positive

A skilled doula empowers a woman to communicate her needs and

perceptions and actualize her dream of a healthy, positive birth
experience.

49

effects of doula care have been found to be greater

for women who were socially disadvantaged, low
income, unmarried, primiparous, giving birth in a
hospital without a companion, or had experienced
language/cultural barriers (Vonderheid,Kishi, Norr,
& Klima, 2011).
One of the key aspects of the involvement of
doulas is that they provide emotional and other
support by maintaining a constant presence
throughout labor, providing specific labor support
techniques and strategies, encouraging laboring
women and their families, and facilitating communication between mothers and medical caregivers.
Studies examining the impact of continuous support by doulas report significant reductions in
cesarean births, instrumental vaginal births, need
for oxytocin augmentation, and shortened durations of labor (Campbell, Lake, Falk, & Backstrand,
2006; Klaus & Klaus, 2010; Newton, Chaudhuri,
Grossman, & Merewood, 2009; Papagni & Buckner,
2006; Sauls, 2002). Continuous support also has
been associated with higher newborn Apgar scores
(greater than 7) and overall higher satisfaction by
mothers with the birthing process (Sauls, 2002).
Others report that many of these effects occurred
when support was provided by someone other than
an attending nurse (Rosen, 2004; Sakala, Declercq,
& Corry, 2002; Sauls, 2002).
The evidence suggests that it is likely more than
the emotional, physical, and informational support
doulas give to women during the birthing process
that accounts for the reduced need for clinical procedures during labor and birth, fewer birth complications, and more satisfying experiences during
labor, birth, and postpartum (Meyer, Arnold, &
Pascali-Bonaro, 2001; Wen, Korfmacher, Hans, &
Henson, 2010). Klaus and Klaus (2010) argue that
the modern hospital birthing process tends to be
highly interventionist, taking away decision making from mothers. This results in many unwanted
and, in many cases, unwarranted procedures.
Medical providers sometimes prefer women to be
compliant and recommend procedures to ward
off pain and discomfort. However, these actions
may actually interfere with birth outcomes, with
mothers counseled to focus on their comfort and
not necessarily on the possible implications of
those interventions on the birth of their baby, the
babys immediate health, or on later complications
from these procedures. A doula serves as a mothers advocate, providing a woman a sympathetic

50

but informed ear for the choices that the birthing

staff may ask her to make during the birthing process (Hazard, Callister, Birkhead, & Nichols, 2009;
Papagani & Buckner, 2006). The doula empowers
decisions that are made in the best interest of both
the mother and her child (Breedlove, 2005; Deitrick
& Draves, 2008).
Studies that examine the relationship between
birthing mothers and their doulas report consistently positive experiences (Deitrick & Draves, 2008;
Hazard et al., 2009; Koumouitzes-Douvia & Carr,
2006). Other studies have noted positive effects into
the postpartum period. Newton et al. (2009), for
example, found among a sample of Latina women
giving birth at a Boston hospital that mothers supported by doulas were more likely to breastfeed
their newborns and to delay first infant formula
feed. Similarly, Nommsen-Rivers, Mastergeorge,
Hansen, Cullum, and Dewey (2009) reported that
in comparison to a group of women receiving standard care (n597), a doula-paired group of women
(n 544) experienced significantly shorter periods
of labor, less instances of instrument-assisted birth,
and better Apgar scores (greater than 7) at 1 minute
postpartum. The doula mothers also experienced
earlier onset of lactogenesis (within 72 hours postpartum) and were more likely to breastfeed their
babies at 6 weeks. In a study of 2,174 expectant
mothers receiving doula services compared with
a sample of 9,297 receiving standard care, MottlSantiago and associates (2007) also found higher
rates of breastfeeding and early initiation rates
among the doula-supported m
others.
Few studies have investigated the birth outcomes
associated with and without the support of a doula.
Campbell et al. (2006), in a study of 300 doula-supported and 300 nondoula-supported low income
women giving birth between 1998 and 2002 at a perinatal care hospital in New Jersey, found that doula
mothers had significantly shorter lengths of labor,
more cervical dilation, and higher Apgar scores at
1 and 5 minutes. No differences were reported in
birth weight or in rates of cesarean births or epidural
anesthesia.
The purpose of this study is to present a comparative analysis of birth outcome results of two groups
of mothers served by the same childbirth education
program. The groups are defined by one receiving
prebirth assistance from a certified doula and the
other representing a sample of birthing mothers
who elected not to work with a doula.

The Journal of Perinatal Education | Winter 2013, Volume 22, Number 1

YWCA GREENSBORO HEALTHY BEGINNINGS

DOULA PROGRAM
This program was launched in 2008 and is focused
on reducing adverse birth outcomes by offering
psychosocial, perinatal support, and wellness programming, including doula support for women
at risk for adverse birth outcomes because of racial disparity (particularly African American and
Hispanic), homelessness, interpersonal violence,
unhealthy housing, poverty, or young age. The
primary goal of this project is to reduce infant
mortality, adverse birth outcomes, low birth
weight (LBW), and prematurity in at-risk pregnant women through a system of psychosocial
support that includes case management, home
visitation, childbirth education, perinatal health,
nutrition and fitness classes, and doula support.
The program follows a life course perspective that
views birth outcomes as the product of the entire life course of the woman, her family, and her
partner and not just the 9 months of pregnancy.
The program offers health education and wellness support in childbirth preparation, breastfeeding initiation, eliminating use and exposure
to tobacco and other toxins, safe sleep, folic acid
consumption, reproductive life planning, healthy
relationships, stress management, healthy weight,
and exercise. The program is based on an empowerment philosophy designed to empower young
mothers, including helping them with seeking
solutions, recognizing their strengths, and expecting themselves to be successful. In the program,
participants are encouraged to clarify their health
goals, identify barriers, learn and use problemsolving techniques, develop communication
skills, and be proactive to reach their healthy birth
goals. One critical mission of the program is to
help participants develop healthy relationships
with family, friends, and helping adults because
these relationships support healthy births (Lu &
Lu, 2007).
The Healthy Beginnings Doula Program (HBDP)
integrates three critical methods of support for
women at risk for adverse birth outcomes: individual
case management, peer group education and support, and doula support. Although prenatal health
and childbirth education traditionally focuses on
pregnancy and doula care focuses more intently on
childbirth, in HBDP these are more integrated and
both begin in early pregnancy. Curriculum content
includes birthing and baby development education,

Impact of Doulas | Gruber et al.

self-care activities, enhanced perinatal health promotion, and peer support. These are all part of
group prenatal education provided to program participants as supplemental to information they may
receive from medical staff providing their prenatal care. Studies have found better birth outcomes
(as measured by birth weight and gestational age)
for women, particularly women of color, when they
receive group-delivered prenatal care as opposed to
just receiving care messages and support on a oneon-one basis (Ickovics et al., 2007). The goal of the
HBDP is to deliver a series of educational messages
and self-care instructional advice that can ameliorate factors that may jeopardize a healthy birth outcome. Risk reduction is achieved through concerted
efforts to promote healthy behaviors, increase health
knowledge, practice effective self-management of
health activities, learn and apply problem-solving
skills, and usesocial s upport.
The HBDP is designed to help women who are
likely at risk for a possible adverse birth outcome
because of psychosocial factors such as low income
and racial disparities. The program helps these
women access appropriate positive support through
the use of doulaswomen trained and dedicated to
providing physical, emotional, and informational
support during the prenatal, intranatal, and postnatal periods. Unlike more traditional doula programs,
the doulas provided through the HBDP are available
to a woman months before going into labor. The
program pairs each expectant mother with a doula
when she is ready to work with a doula. This provides the opportunity for doulas to offer support
tailored to the expectant mothers specific needs
through prenatal health visits and preparation for
labor and birth.
Doulas who serve the HBDP are often female
volunteers from the same communities as the
women who receive their services. The volunteers
participate in Doulas of North America (DONA)
certified training program and are trained to
provide practical and emotional support to pregnant women and their families before, during,
and after birth. After completion of training, the
doula volunteers receive continuing education
on a monthly basis from the project coordinator
and staff. Once paired with an expectant mother,
a doula meets with her a minimum of two times
before the birth, offers continuous assistance
throughout labor and birth, and visits her at least
twice postpartum.

51

METHOD
Doulas
During the period of this study, 47 women served
as birth doulas to the women in this sample. They
ranged in age from 22 to 59 years. About half were
under the age of 30 years. Most of the doulas were
either White (44%) or African American (41%).
Most (87%) had attended at least some college;
slightly more than two thirds were college graduates. About half of the doulas worked in professional
occupations including program managers, educators, or nurses. The rest were nonprofessionals such
as homemakers, technicians, food service workers,
or students.
THE HEALTHY MOMS HEALTHY BABIES
CHILDBIRTH EDUCATION CLASSES
In addition to being paired with a doula, program
participants were offered 8-week childbirth education classes. These classes included health education
on folic acid, nutrition, breastfeeding, smoking and
substance abuse cessation, safe sleeping, purple crying, neonatal care, and maternal mental health. The
classes were conducted in the context of a peer support model similar to Centering Pregnancy, a best
practice model. All expectant participants received
individual support through case management including weekly phone calls and semimonthly or
more frequent home visits as needed.
Assignment of Doulas to Expectant Mothers
Expectant mothers who attended at least three of the
eight childbirth classes were given the option to have
a doula. Program coordinators and childbirth instructors introduced individual doulas and provided
information about available doulas in each childbirth
class. Participants were matched with doulas based
on the availability of the doulas near the mothers
expected due date as well as compatibility on a number of other attributes (e.g., language, race/ethnicity,
personality). Once all these factors were evaluated,
case managers matched the mothers with a primary
doula and a backup doula in case the primary
doula was not available when the mother went into
labor. The role of HBDP doulas was not limited to
just the labor and birth process. Most of the pregnant women participating in the program were connected with a doula shortly after they entered the
program. For many of these mothers, this enabled
the doulas to provide support and encouragement
regarding prenatal visits long before the visit to the

52

hospital to give birth. Others have reported similar

positive connections with prenatal care following
pairing pregnant women with a doula (e.g., Deitrick
& Draves, 2008). Many doulas also attended childbirth education classes with the expectant mothers.
The doulas met with the expectant mothers two
times before the birth, offered continuous assistance
throughout labor and birth, and visited them at least
two times postpartum. The doulas ideally arrived at
the hospital before the mother was at 4 cm during
labor and stayed for about an hour after the birth.
The doulas kept the women comforted, informed,
and empowered during labor and facilitated communication with both hospital staff and personal
support people so that the mothers felt in control
of their medical decisions and birth experience. The
doulas helped with newborn care and breastfeeding
right after birth.
Program Participants
The expectant mothers included in the sample were
identified by health professionals, social workers,
counselors, school nurses, obstetrics and gynecology
(OB/GYN) offices, nonprofit agencies, schools, college campuses, community settings such as churches
and libraries, through peers, and self-referral. Participants were mostly low income, in school, in unskilled
jobs or unemployed, and living in neighborhoods
characterized by poverty, high rates of unemployment, crime, substance abuse, interpersonal violence,
and lack of educational attainment.
This study used a nonexperimental design with
assignment to groups (doula vs. nondoula) based on
whether the participant in the program used a doula
in preparation for birth and delivery. All analyzed
data were collected as a routine part of program services. This study was conducted in accordance with
the human subjects protection guidelines of the first
authors university.
Two hundred eighty-nine pregnant females (ado
lescents and young adults aged 1330 years) were
served by the YWCA Greensboro between January
2008 and December 2010. Inclusion in the sample
for this study was limited to expectant mothers who
attended at least three Healthy Moms Healthy Babies
childbirth classes. The YWCA considers attendance
at two or fewer childbirth classes as representing
insufficient exposure to the programs philosophy
and birth preparation information. Based on this
criterion, the sample for this study was composed
of 226 expectant mothers who participated in at

The Journal of Perinatal Education | Winter 2013, Volume 22, Number 1

least three of the childbirth classes. Of these, 129

gave birth without the assistance of a doula, and 97
worked with a doula. The birth weight of the baby
of one nondoula mother was not recorded, and this
case was eliminated from the sample resulting in 128
nondoula-assisted cases. The data sample provided
the opportunity to conduct a comparison of the impact of doula versus nondoula assistance on birth
outcomes.
The race/ethnicity and distribution of age of the
sample are presented in Table 1. The data show that
the two groups were very similar by race/ethnicity
with most of both groups represented by women
who identified themselves as African American. The
age of the two groups was comparable; the nondoula
group was slightly younger than the doula group.
Also presented in Table 1 was with whom the
mothers reported living at the time of the birth of
their babies. The data show that nondoula mothers
were significantly more likely to be living with family or guardians than the doula mothers. Conversely,
doula mothers were significantly more likely to be
living with partners or nonfamily (33.0%) than
the nondoula mothers (13.3%). The difference was
mostly because of the percentage of nondoula adolescent mothers living with family/guardian (74.7%)

TABLE 1
Race/Ethnicity, Age, and Living Situation of the Mothers
in the Sample

Mothers With
Doulas
(N 5 97)

Nondoula
Mothers
(N 5 128)
Race/Ethnicity

African American
White
Other
Mean age
Median age
Age range
Living situation
Alone
Family/guardian
Friends
Partner
Other
Not reported

101
8
19

78.9
6.3
14.8

75
8
14

77.3
8.2
14.4

19.1
18.3
1330
7
88
2
10
5
16

20.3
20.0
1331
5.5
68.8a
1.6b
7.8b
3.9b
12.5

7
43
10
15
7
15

7.2
44.3a
10.3b
15.5b
7.2b
15.5

Note. Percentages with same superscript were compared using a

z-test analysis.
a
z score 5 3.68, p , .0003, CI 5 95%.
b
z score 5 3.54, p , .0004, CI 5 95% (based on combination of
friends 1 partner 1 other).

Impact of Doulas | Gruber et al.

as compared with 47.1% of doula-assisted teenage

mothers. Percentages of adults living with family
at the time of birth were 56.1% and 41.3%, nondoula/doula mothers, respectively. One additional
characteristic of note for the two samples was that
at the time of intake into the program, both groups
reported low levels of expected support (not including doulas) at labor18.0% for nondoula mothers
(18.4% of adolescents/17.1% of adults) and 19.6%
of doula mothers (13.7% of adolescents/26.1% of
adults).
Impact Measures
The impact of having a doula was assessed by the
following measures: (a) type of birth, (b) incidence
of having a LBW baby, (c) incidence of complications at birth for either the mother or baby, and (d)
incidence of initial breastfeeding.
Comparative Analyses
Proportions were compared using z-test analysis
(Joosse, 2011). P values of less than .05 were used
for identification that proportions were significantly
different.
RESULTS
Type of Birth
A summary of the number and percentages of the
type of birth by whether the mother was an adolescent or adult and doula or nondoula assisted is presented in Table 2. From the table, it can be seen that
there were minimal differences by age group or doula
assistance status, although the rates of cesarean birth
were higher for nondoula-assisted mothers. More
than three fourths of births were vaginal; more than
half involved an epidural.
Incidence of Low Birth Weight
The incidence of LBW births (less than 5.5 lb) is presented in Table 3. Comparisons of the percentage of
LBW births between doula and nondoula mothers
by adolescent and adult groups showed no statistical significance. However, the comparison of the age
group samples combined yielded a significant difference. Nondoula-assisted mothers were four times
more likely to have an LBW baby than mothers who
were assisted by a doula.
Birth Complications
The number of births involving a medical issue relating to either the mother or her baby is presented

53

TABLE 2
Type of Birth

Adolescents
Nondoula mothers
Vaginal
Vaginal 1 epidural
Cesarean
Not reported
Total
Mothers with doulas
Vaginal
Vaginal 1 epidural
Cesarean
Total

Adults

Total

19
48
19
1
87

21.8
55.2
21.8
1.1
100.0

9
20
12

41

22.0
48.8
29.3

100.0

28
68
31
1
128

21.9
53.1
24.2
0.8
100.0

11
27
8
46

23.9
58.7
17.4
100.0

15
25
11
51

29.4
49.0
21.6
100.0

26
52
19
97

26.8
53.6
19.6
100.0

Note. None of the compared percentages between groups was significant.

in Table 4. The rates of complications for adolescents and adults for doula versus nondoula-assisted
mothers, although higher for the nondoula mothers,
were not statistically different.
Initiation of Breastfeeding
Initiation of breastfeeding percentages are presented
in Table 5. The data show that about two thirds of
the adolescents in both the nondoula- and doulaassisted groups reported initiating breastfeeding.
For the adults, nearly all of the mothers in the doula-assisted groups initiated breastfeeding compared
with slightly less than three fourths of the nondoulaassisted adults. Overall, the adult and the combined
TABLE 3
Number and Percentage of Low Birth Weight

Low Birth
Weight
(,5.5 lb)
Babies

Cases
Nondoula mothers
Adolescents
Adults
Total
Mothers with doulas
Adolescents
Adults
Total

87
41
128

68.0
31.8
100.0

5
6
11

5.7a
14.6b
8.6c

46
51
97

47.4
52.6
100.0

0
2
2

0.0a
3.9b
2.1c

Note. Percentages with same superscript were compared using a z-test

analysis.
a
z score 5 1.15, p . .05.
b
z score 5 1.47, p . .05.
c
z score 5 1.78, p , .04, CI 5 95%.

54

sample of adolescent and adult doula-assisted

mothers reported significantly greater percentages
of breastfeeding initiation compared with their
adult and combined adult and adolescent nondoula
counterparts.
DISCUSSION
The results show that expectant mothers matched
with a doula had better birth outcomes than did
mothers who gave birth without involvement of a
doula. Doula-assisted mothers were four times less
likely to have a LBW baby, two times less likely to
experience a birth complication involving themselves or their baby, and significantly more likely to
TABLE 4
Number and Percentage of Births With Complications to
Either the Mother or the Baby

Cases
f

18

20.7a

Adults (n 5 41)

17.1b

Total (N 5 128)

25

19.5c

Adolescents (n 5 46)

10.9a

Adults (n 5 51)

9.8b

Total (N 5 97)

10

10.3c

Nondoula mothers
Adolescents (n 5 87)

Mothers with doulas

Note. Percentages with same superscript were compared using a z-test

analysis.
a
z 5 1.45 p . .05.
b
z 5 0.75 p . .05.
c
z 5 1.91 p , .04, CI 5 95%.

The Journal of Perinatal Education | Winter 2013, Volume 22, Number 1

Doula-assisted mothers were four times less likely to have a

TABLE 5
Number Reporting Initiation of Breastfeedinga

Nondoula
Mothers
(N 5 128)
Adolescents
Adults
Total

Mothers With
Doulas
(N 5 97)

56
30
86

64.4b
73.2c
67.2d

31
46
77

67.4b
90.2c
79.4d

Note. Percentages with same superscript were compared using a z-test

analysis.
a
Includes feeding at breast or milk expression.
b
z 5 0.25, p . .05.
c
z 5 1.91, p , .04, CI 5 95%.
d
z 5 1.84, p , .03, CI 5 95%.

initiate breastfeeding. With the exception of breastfeeding, comparison of adolescent and adult expectant mothers was not significantly different on these
outcomes. Nearly all (90.4%) of the adult mothers
assisted by a doula chose to initiate breastfeeding.
Although it cannot be determined conclusively
that having a doula was the reason for the greater
likelihood of positive birth outcomes, this deserves a
strong consideration because of the fact that the two
groups of mothers were in most ways indistinguishable. They were similar in age, race/ethnicity, income
status, and geographic location. All of the mothers
had participated in at least three of the agencys childbirth classes, and all received case management as
part of their participation with the agency. They did
differ in terms of with whom they were living prior
to birth, with the doula group more likely to be living
with partners or nonfamily others compared with the
nondoula group who were far more likely to be living
with family (not including partners). This difference,
however, did not relate to higher frequencies of expected birth support for the nondoula mothers. As a
group, there was a significant 15% difference between
expected support reported by doula-assisted mothers
and that reported by the nondoula-assisted mothers. This means that even though more of the doulaassisted mothers expected support from someone
close to them at prebirth or birth, they also wanted
to have additional support, which was provided to
them by a doula. Although not collected systematically as part of this study, doulas and case managers
reported that mothers who had a doula were positive
about the support they received from doulas prior to
the prenatal period and during labor and birth. These

Impact of Doulas | Gruber et al.

LBWbaby, two times less likely to experience a birth complication

involving themselves or their baby, and significantly more likely to
initiate breastfeeding.

reports underscore the value of doulas as sources of

dependable and consistent support.
Although the primary focus of this article was to
report the positive impact on birth outcomes for an
at-risk group of mothers, it is important to note that
the doulas were not a completely independent source
of information and support. Their role was supplemented by the combination of peer group support
(including prenatal health and fitness classes, health
literacy) and peer group education and individual
support (in the form of case management and doulas) provided through the YWCAs Healthy Moms
Healthy Babies childbirth education classes. In these
classes, participants learned about prenatal care; reproductive life planning; prenatal fitness and healthy
nutrition; multivitamins and folic acid; and information on breastfeeding, healthy relationship formation,
nutrition and cooking, stress management, and safe
and secure housing. Doula- and nondoula-assisted
mothers participated in the same childbirth classes.
It is notable that despite participating in the same
education classes, the women who chose to work
with a doula had significantly better birth outcomes
as measured by birth weight and fewer birth complications. This finding suggests that women who embraced the premise that a doula may help empower
them to influence their birthing experience, manage
their labors more effectively, and reach their expectations and hopes for a positive, healthy birth also may
have realized that they could improve their prenatal
health and the likelihood of a healthy birth outcome
through their active participation and engagement in
the healthy prenatal activities offered by this program.
Why some of the expectant mother chose to work
with a doula, whereas others did not remains an
open question. One possibility is those who chose
to work with a doula believed that it would enhance
the information and support they were getting from
the childbirth classes. Conversely, those who were
not convinced that a doula could improve their birth
experience may have also been less influenced by the
other components of this program and the belief that
their behavior changes could improve their chances

55

for a healthy birth weight baby. Another possibility is

that the women who chose doula support were most
in need of support (Gilliland, 2002). If this is true,
then their significantly better birth outcomes are
even more noteworthy. Perhaps they did not have significant other people who were willing or able to help
them during labor and birth. However, it is equally
plausible that those who chose doula support were
able to benefit from this support and reduced impact
of factors associated with adverse birth outcomes.
Because the doula group was more likely to be living
on their own or with a partner, this might indicate
they were more comfortable involving others outside
of their family or support group. These possible connections and potential for positive impact on birth
outcomes warrant further investigation.
Limitations
One limitation of this study is that participants selfselected themselves to work with a doula. Conceivably,
expectant mothers who perceive the need or like the
idea of having someone such as a doula assist them at
the time they give birth are different than those who do
not and take extra precautions for increasing the chance
of a healthy birth. In this study, the decision to work
with a doula was likely as much a critical determinant
of birth outcomes (as defined by birth weight) as the
actual support activities the doula provided. Another
limitation was that there was no information on who
else was involved in providing support to the mothers
leading up to birth. Because having a doula was selfdetermined, it may have been that mothers choosing to
have a doula did so because there was no one else. It is
more likely, however, that rather than being isolated,
expectant mothers who chose to work with a doula
were interested in sources that could reduce the stress
associated with having a baby and navigating the birth
process. Finally, as noted, the doula involvement was
not independent of other services and support received
by program participants. It is possible that the doula
experience amplified messages and recommendations
provided by others involved in the expectant mothers
lives. Because the doulas were assigned to interested
participants in the beginning of their involvement with
this program, they had time to discuss the birthing experience and to bond with expectant mothers and to
help them prepare for delivery and birth of the baby.
CONCLUSION
Doulas can empower women to achieve the best
birth outcomes possible, and all outcomesfor

56

births, infants, and mothersseem to be affected

more positively if support is provided by a doula
in addition to the medical personnel. The doula
focuses on individualized support before, during,
and after birth; whereas nurses often are attending
to several women in labor and responsible for many
clinical and administrative tasks besides direct labor support. Research indicates that the expectation
of nurse support by expectant women may be far
greater than what is actually provided (Tumblin &
Simkin, 2001). Hospitals could address this disparity
by including a system of doula support.
Although all women in this program received education and support from staff and peers, the extra
dimension of a doula may have increased the empowerment and motivation of women to improve
their health prenatally. Women are motivated to
have healthy babies. They are also motivated to have
manageable labor and birth experiences. Women
who embraced the idea that doula support could improve their locus of control in labor and birth may
have increased and acted on their belief that their
prenatal health behaviors would improve their birth
outcomes (Weisman et al., 2008). HBDP is part of a
complex of programs offered by the YWCA intended
to help women increase not only their knowledge
and practice of healthy prenatal behaviors but also
their self-efficacy and informed decision making in
developing and implementing healthy behaviors.
The involvement of a doula seems to magnify the
impact of these programs resulting in even better
birth outcomes and birth experiences.
Implications for Childbirth Educators and Nurses
This study reinforces the case that doula involvement
is a cost-effective method to improve outcomes for
mothers and infants. Furthermore, this study demonstrates that doulas can have an impact beyond the
birth process itself (reducing cesarean births, birth
complications, and medical interventions as has been
shown in other studies) and the mothers experience of the birth (resulting in increased satisfaction,
mother/baby attachment, and breastfeeding). Doula
assistance in this case seems to have impacted health
choices of expectant mothers during pregnancy,
resulting in lower risk of LBW births. Doulas may
have enhanced processing and internalization of the
information presented in the group childbirth education classes. Communication with and encouragement from a doula throughout the pregnancy may
have increased the mothers self-efficacy regarding

The Journal of Perinatal Education | Winter 2013, Volume 22, Number 1

her ability to impact her own pregnancy outcomes.

Support from a doula and the security of knowing
she would be present at the birth may have reduced
a measure of the stress and anxiety experienced by
the mother. In light of these outcomes, practitioners
should consider doulas as a part of an enhanced prenatal group care program to improve birth outcomes
and involve them early in the pregnancy.
This study indicates that the inclusion of doulas
in the prenatal period, at a point when behavioral
changes can most impact birth outcomes, is most
effective. Therefore, if obstetricians and other birthing professionals could include a plan of doula support in the prenatal period, adverse birth outcomes
associated with a lack of social support or for women
in general could be reduced. This would benefit the
women and babies, medical practitioners, hospitals,
and the greater community in reducing the financial
and personal costs of adverse birth outcomes.
Offering doulas as part of a menu of choices in
the prenatal period would be a way to empower
women to be actively involved in preparing for birth
and developing self-efficacy in maternal health behaviors. Women offered evidenced-based health
information, support in improving their prenatal
health behaviors, and the kinds of support provided
by doulas are likely to make more informed choices
throughout the pregnancy regarding their health
and that of their baby.
The results of this study indicate that if offered
a comprehensive system of psychosocial and health
support, socially disadvantaged women can improve
their birth outcomes. The women served by this
project often do not believe they can impact their
health or their birth outcomes. Practitioners who
work with them also often have little confidence that
they can help disadvantaged women change their
health behaviors and improve their birth outcomes.
This study indicates that both of these groups can
build their self-efficacy and together, as partners
in this journey, improve birth outcomes. Based on
the empowerment model, both the mothers and
the practitioners need to be copilots in improving
health behaviors. Doulas, as part of a comprehensive
system of support, can help m
ediate this process.
Future research should attempt to isolate the variables that resulted in positive outcomes in this case.
Questions to be examined include individual compared to group care with doula assistance, the optimal time for doula involvement, the role of informed
decision making in birth outcomes, and perceptions

Impact of Doulas | Gruber et al.

and decision-making processes of women in opting

for the support of a doula.
Hospital and community health policy may benefit from enhanced prenatal health and childbirth
education and support including doula assistance
for all women but particularly for women at risk for
adverse birth outcomes because of homelessness,
racial disparities, adolescence, violence, and lack
of psychosocial support. This support empowers
women to take charge of their own prenatal health,
thus improving birth outcomes.
REFERENCES
Breedlove, G. (2005). Perceptions of social support from
pregnant and parenting teens using community-based
doulas. Journal of Perinatal Education, 14(3), 1522.
Campbell, D. A., Lake, M. F., Falk, M., & Backstrand, J.R.
(2006). A randomized control trial of continuous support in labor by a lay doula. Journal Obstetrics and
Gynecologic Neonatal Nursing, 35(4), 456464.
Deitrick, L. M., & Draves, P. R. (2008). Attitudes towards
doula support during pregnancy by clients, doulas, and
labor-and-delivery nurses: A case study from Tampa,
Florida. Human Organization, 67(4), 397406.
Gilliland, A. L. (2002). Beyond holding hands: The modern role of the professional doula. Journal Obstetrics
and Gynecologic Neonatal Nursing, 31(6), 762769.
Hazard, C. J., Callister, L. C., Birkhead, A., & Nichols, L.
(2009). Hispanic labor friends initiative: Supporting
vulnerable women. The American Journal of Maternal
Child Nursing, 34(2), 115121.
Ickovics, J. R., Kershaw, T. S., Westdahl, C., Magriples, U.,
Massey, Z., Reynolds, H., . . . Rising, S. H. (2007). Group
prenatal care and perinatal outcomesa randomized controlled trial. Obstetrics and Gynecology, 110(2), 330339.
Joosse, S. A. (2011). Two-proportion Z-test calculator.
Retrieved from http://in-silico.net/statistics/ztest
Klaus, M., & Klaus, P. (2010). Academy of Breastfeeding Medicine Founders Lecture: Maternity care reevaluated. Breastfeeding Medicine, 5(1), 38.
Koumouitzes-Douvia, J., & Carr, C. A. (2006). Womens
perception of their doula support. Journal of Perinatal
Education, 15(4), 3440.
Lu, M., & Lu, J. (2007). Maternal nutrition and infant
mortality in the context of relationality. Washington,
DC: Joint Center for Policy and Economic Studies,
Health Policy Institute.
Meyer, B., Arnold, J., Pascali-Bonaro, D. (2001). Social support by doulas during labor and the early postpartum
period. Hospital Physician, 37(9), 5765.
Mottl-Santiago, J., Walker, C., Ewan, J., Vragovic, O.,
Winder, S., & Stubblefield, P. (2007). A hospital-based
doula program and childbirth outcomes in an urban,
multicultural setting. Maternal and Child Health
Journal, 12(4), 372377.
Newton, K. N., Chaudhuri, J., Grossman, X., & Merewood,
A. (2009). Factors associated with exclusive breastfeeding among Latina women giving birth at an inner-city

57

baby friendly hospital. Journal of Human Lactation,

25(1), 2832.
Nommsen-Rivers, L. A., Mastergeorge, A. M., Hansen,
R.L., Cullum, A. S., & Dewey, K. G. (2009). Doula care,
early breastfeeding outcomes, and breastfeeding status
at 6 weeks postpartum among low-income primiparae.
Journal Obstetrics and Gynecologic Neonatal Nursing,
38(2), 157173.
Papagni, K., & Buckner, E. (2006). Doula support and
attitudes of interpartum nurses: A qualitative study
from the patients perspective. Journal of Perinatal
Education, 15(1), 1118.
Rosen, P. (2004). Supporting women in labor: Analysis
of different types of caregivers. Journal of Midwifery
Womens Health, 49(1), 2431.
Sakala, C., Declercq, E. R., & Corry, M. P. (2002). Listening
to mothers: The first national U.S. survey of womens
childbearing experiences. Journal of Obstetric, Gyne
cologic, and Neonatal Nursing, 31(6), 633634.
Sauls, D. J. (2002). Effects of labor support on mothers,
babies, and birth outcomes. Journal of Obstetric,
Gynecologic, and Neonatal Nursing, 31(6), 733741.
Tumblin, A., & Simkin, P. (2001). Pregnant womens perceptions of their nurses role during labor and delivery.
Birth, 28(1), 5256.
Vonderheid, S. C., Kishi, R., Norr, K. F., & Klima, C. (2011).
Group prenatal care and doula care for pregnant
women. In A. Handler, J. Kennelly, & N. Peacock
(Eds.), Reducing racial/ethnic disparities in reproductive
and perinatal outcomes: The evidence from populationbased interventions (pp. 369399). http://dx.doi.org
/10.1007/978-1-4419-1499-6_15

58

Weisman, C. S., Hillemeier, M. M., Chase, G. A., Misra,

D.P. Chuang, C. H., Parrott, R., . . . Dyer, A. M. (2008).
Womens perceived control of their birth outcomes
in the Central Pennsylvania Womens Health Study:
Implications for the use of preconception care. Womens
Health Issues, 18(1), 1725.
Wen, X., Korfmacher, J., Hans, S. L., & Henson, L. G.
(2010). Young mothers involvement in a prenatal and
postpartum support program. Journal of Community
Psychology, 38(2), 172190.

KENNETH J. GRUBER is a Doctor of Philosophy in

Social Psychology and is a senior research and evaluation
consultant for the Center for Youth, Family, and Com
munity Partnerships at the University of North Carolina,
Greensboro. His research interests include adolescent preg
nancy prevention and healthy birth outcomes. SUSAN H.
CUPITO has Master of Arts degree in Clinical Psychology
and holds licensure as a professional counselor in Ohio. She
is the director of the Healthy Moms Healthy Babies and Teen
Parent Mentor Program at the YWCA in Greensboro, North
Carolina and has more than 25 years of experience work
ing with young mothers who face significant psychosocial
challenges. CHRISTINA F. DOBSON earned her Master
of Arts in Education at the University of Michigan. She has
13 years of experience at the YWCA of Greensboro develop
ing and implementing programs for pregnant and parenting
adolescents and young adult women at risk for adverse birth
outcomes.

The Journal of Perinatal Education | Winter 2013, Volume 22, Number 1