Playing the Doula Numbers Game

If you’re a doula, you’ve probably heard “the stats” about doulas. The famous numbers that show a powerful effect from doula care:

• 50% reduction in cesarean rate
• 25% shorter labor
• 60% reduction in epidural requests
• 30% reduction in pain medication use
• 40% reduction in forceps delivery
• 40% reduction in oxytocin (pitocin) use

But where do these stats come from? Well, they come from the book “Mothering the Mother” by and Marshall Klaus, John Kennell u0026amp; Phyllis Klaus. These numbers were calculated by looking at all of the studies done on labor support up until the book was prepared for publication. The numbers have been around for a very long time – the book was published in 1993. To give you an idea how old those numbers are, my oldest daughter was born that year, and she’s currently busy driving, dating, and starring in her high school musical. And because in 1993 the authors were reviewing past studies, the actual studies are even older. Some studies are likely older than the expectant moms you work with. The oldest one reviewed in Mothering the Mother was published in 1980, so the births in the study likely happened in the late 1970s!

Suffice it to say that those numbers are not current by any stretch of the imagination! There has been quite a bit of research done into doula work in the last 16 years, and those who are promoting doulas would be very well served to be familiar with the newest research.

The newer research does not give “the stats” in nice, easy percentages, but the information that is there is far less dramatic. For example, the most recent Cochrane review on doulas shows a reduction in the length of labor as only 26 minutes. Still a significant difference, but much less impressive than the 25% cited in “Mothering the Mother”.

There are several reasons for this effect.

First, with a smaller sample size you tend to have a wider confidence interval. This is similar to the +/- numbers you sometimes see in political polls reported on the news. A wider confidence interval means the real number could fall anywhere in that range. In the more recent reviews, the larger numbers have made it possible to get pretty narrow confidence intervals. The most recent Cochrane review on doulas had nearly ten times the number of births included in the original Mothering the Mother.

Secondly, much of the more recent research has been done in different situations than where most doulas are working. Almost half of Klaus, Kennell u0026amp; Klaus’s numbers came from a small hospital in Guatemala with no access to anesthesia. These numbers may not be applicable to women birthing in a hospital with ready access to anesthesia.

Also, in the Guatemalan studies, the mom did not have any family or friend support. No moms, sisters, or even husbands were in attendance at any of the births. The moms who did not have doulas had no one supporting them. Again, this is not the case for the majority of births in much of the world where doulas practice.

Third, the initial 6 studies all used only first time moms expecting a single baby. The general population of births is not all first time moms, and so the dramatic results may only apply to first births. Later studies have included more than just first time moms.

While it might be nice to be able to claim the earlier – and more impressive – statistics, it shows more professional integrity to be current. Plus, there are some interesting new findings from the more current research:

• The results for three different outcomes (analgesia/anesthesia, spontaneous vaginal birth, and instrumental vaginal birth) are significantly stronger when the support person is not a member of the hospital staff. The Cochrane reviewers speculate that “divided loyalties, additional duties beyond labour support, self-selection, and the constraints of institutional policies and routine practices may have all played a role.” (Hodnett, Gates, Hofmeyr u0026amp; Sakala, 2008 p. 10)
• Women who receive doula care are 27% less likely to be dissatisfied with their births as compared to women who did not use a doula. (based on the reports of 6 studies totaling 9824 women. RR=.73; 95% CI .65-.83)
• Women in the doula care group were significantly more likely to have a spontaneous vaginal birth (based on the reports of 15 studies totaling 13,357 women. RR=1.07; 95% CI 1.04-1.12).
• Mothers receiving doula care are significantly less likely to feel a loss of control in labor. (based on the reports of 2 studies totaling 7369 women. RR=.79 95% CI .67-.94)
• The results for three outcomes (analgesia/anesthesia, spontaneous vaginal delivery, cesarean rate) were significantly stronger when labor support began before active labor.

So if using the old percentage numbers from Mothering the Mother is not the best idea, how can you present the data to your clients?

Well, the best way might be to avoid numbers at all. The research has pretty consistently found the nearly the same significant benefits, though the actual numbers may vary. (The only one that has not held up is the reduction in pitocin use.) You could take the approach used by DONA International, and use a table showing increase/decrease alone without numbers.

If you have been in practice for a while and have kept good records of YOUR stats, you could present your results as compared to your local stats.

Either way, if you want to use research data to promote your doula practice, being familiar with current data is essential.