Intrapartum Doula Support and Cesarean Delivery Rates

OBJECTIVE: To estimate the association between doula support and cesarean delivery compared with standard of care. DATA SOURCES: We conducted a systematic review of randomized controlled trials (RCTs) and observational studies comparing in-person intrapartum doula support with standard care. We searched studies published in Ovid Medline, Embase.com , Scopus, Cochrane Central, and ClinicalTrials.gov before August 30, 2024. The primary outcome was cesarean delivery. Secondary outcomes included operative vaginal delivery, low 5-minute Apgar score, and regional anesthesia. METHODS OF STUDY SELECTION: Titles, abstracts, and articles were screened and reviewed by two authors. Eighteen studies were included in the final analysis (n=367,662): eight RCTs (n=2,497) and 10 observational studies (n=365,165). The primary analysis was restricted to RCTs. Additional analyses were limited to studies that were observational, high quality (Downs and Black quality score in top quartile), or RCTs conducted in the United States. TABULATION, INTEGRATION, AND RESULTS: Random-effects models were used to calculate pooled relative risks (RRs) and weighted mean difference. Heterogeneity was assessed with the Cochran Q test and I2 statistic. Intrapartum doula support was associated with a lower rate of cesarean delivery compared with standard care in RCTs (n=7, 17.5% doula support vs 23.6% standard care, pooled RR 0.71, 95% CI, 0.53-0.95). However, there were substantial study heterogeneity ( I2 =60.1%) and borderline evidence of small-study effects, which could suggest publication bias (Harbord test P =.046). Patients receiving intrapartum doula support in RCTs had significantly lower rates of operative vaginal delivery (n=5, 7.9% doula support vs 13.2% standard care, pooled RR 0.64, 95% CI, 0.44-0.94, I2 =46.0%) but no difference in low 5-minute Apgar score (n=3, 1.6% doula support vs 4.1% standard care, pooled RR 0.47, 95% CI, 0.16-1.34; I2 =0%) or regional anesthesia (n=7, 57.3% doula support vs 69.5% standard care, pooled RR 0.64, 95% CI, 0.36-1.12, I2 =98.75%). Findings were similar in a sensitivity analysis limited to high-quality studies. Doula support was associated with lower cesarean delivery rates among all subgroup analyses except RCTs in the United States (four studies, 16.1% doula support vs 22.2% standard care, pooled RR 0.71, 95% CI, 0.47-1.06). CONCLUSION: Intrapartum doula support was associated with lower rates of cesarean delivery. Results were consistent across study types and when limited to high quality studies; however, significant heterogeneity and concern for publication bias were noted. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42023423577.