Emily Oster

7 min Read Emily Oster

Emily Oster

Why You Might Want a Doula

What's behind one the best-established pieces of evidence in maternity care?

Emily Oster

7 min Read

I try not to give too much direct advice about pregnancy and parenting. As part of my general mantra that there are many good ways to parent, it seems counterproductive to boss people around. However: one peice of advice I will commonly give is to get a doula.

Very broadly, a doula is someone who provides support and care during birth and the postpartum period. Doulas do not have training as medical professionals but, instead, are (usually) women who have some training and experience with birth, and can help with comfort during labor and emotional and personal support afterward.

The idea of a doula traces back more or less forever in human existence. It is a rare society in which women give birth alone, and, commonly, other women were the support structure during labor and delivery. This became less true as births moved out of homes and into hospitals — the medicalization of the birth process would appear to mean less need for these kinds of supports.

However, in the 1970s the idea of doulas as a presence even during hospital births became more popular (perhaps as part of a move toward “natural” birth during this period). Practitioners at this time began to see what they perceived as evidence that having a doula improved birth outcomes.

In my view, the value of doulas in birth is among the best-established pieces of evidence in maternity care. In the first part of today’s post, I’m going to try to briefly convince you of that. In the second part, I’ll talk about issues of expanding access.

Evidence on doulas

There are large-scale randomized studies of the efficacy of doulas. Randomized data is necessary here, because (for some of the access reasons I’ll talk about later) on average, doula access is greater for families with more resources. A direct comparison of those who use a doula to those who do not would therefore run into problems.

Better is to randomize access to a doula. An example is this study, which recruited about 450 women and randomly assigned half of them a doula who arrived shortly after they did at the hospital. The study found that the group assigned a doula had significantly less use of cesarean sections and less use of epidurals. Another, slightly smaller, study showed lower epidural rates and, notably, a significant improvement in satisfaction during labor.

A summary by the Cochrane review aggregates across many studies and argues that there is consistent evidence for lower use of cesarean sections and, in some settings, less use of epidurals. Some evidence suggests doula care before birth can reduce prematurity. As always, there aren’t as many large studies as we would like, but the data does all point in a similar direction.

It is worth a note on the outcomes here. Research tends to focus on cesarean section rates and the use of epidurals, as both are medical interventions that are thought to be less likely with more labor support. This isn’t to say that cesarean sections and epidurals are bad or unnecessary; they can be quite positive experiences. As you know, much of my writing on pregnancy is about the importance of making decisions that work for you, based on data and other personal factors. While what happens during labor is largely out of one’s control, the evidence shows that we see fewer of these interventions when doulas are present.

I wanted to call out what was, for me, among the most surprising studies in this literature. In this paper, the authors run a randomized trial in which the treatment group is asked to identify a female friend who is then given a few hours of doula training. Unlike the hospital-based studies, in which the doulas are professionally trained, these are simply women who are friends of the birthing person, who are given some small amount of training. This intervention resulted in women waiting a longer time before getting an epidural and, strikingly, higher Apgar scores at 1 and 5 minutes. The researchers also found a lower cesarean section rate, although it was not significant.

After, the authors did a longer-term follow-up by telephone and reported that the women who had their friend trained as a doula reported more positive perceptions about their infant, more support from others, and a greater sense of self-worth. They were more likely to breastfeed and to be happy with their hospital care.

This is just one study but, I believe, one that deserves attention and follow-up. If you can, in fact, improve birth outcomes by encouraging people to find a friend to get some minimal education in this area, that seems … pretty notable? And perhaps we could do even better if we invested more in professional doula training.

Final point: Doulas often provide postpartum support (including home visits after birth) as well. Data suggests that this support can improve outcomes, including breastfeeding success and infant care. This means there is an argument for having a doula even if you knew that you were going to have a cesarean section, although the strongest evidence is in the value of labor support.

A reasonable question before getting to policy is why this would work. Doulas are trained in labor positioning and in massage, and, if they’ve seen other births, they provide a sense of calm. But the data on friend training suggests that there must be something about the continuous support, even outside of very formal training and experience. Maybe just having someone to rub your back and tell you you’re doing great is actually really important.

Whatever the reason, that’s the data. If you have the resources for a doula, it is among my strongest recommendations for birth. But not everyone does, which leads me to the next question.

How do we get more doulas?

Doulas are mostly not covered by insurance. The result is that they are more common among families with more resources. This is especially shameful since much of the evidence we have suggests they would be incredibly valuable for women who have fewer resources. We’ve talked here before about the crisis in Black maternal health. There is a strong case to be made that improving doula access could be one way to make a little progress on this crisis. Much of the evidence shows doula care can be especially helpful for Black women.

One very clear way to get more doula support would be to encourage it to be covered by insurance. A closely related way to use this to reduce birth inequality would be to have it be covered by Medicaid. There are cost-based arguments for doing so. For example, this paper argues that because of the possible reductions in preterm birth, it would be cost-effective for Medicaid to reimburse doulas at about $1,000 per birth.

To calculate this, the authors note that babies born preterm are more expensive than those born full-term (they need more support, spend more time in the hospital, use more services). For the insurer, in this case Medicaid, they would save money if fewer babies were born preterm. If doulas reduce the preterm birth rate, then doulas save the insurer money. Combining these calculations, the authors suggest that you’d break even if you gave everyone a doula at $1,000 each. One could imagine similar calculations about cesarean section rates and epidurals, and other studies have shown similar things.

Of course, this ignores the other benefits (like less fear, greater maternal satisfaction) that aren’t quantified. But what it says to me is that even based on just pure cost concerns, it is possible it would make sense for Medicaid to finance a doula for everyone. It might literally be free money.

In the meantime, providing doulas to a broader swath of women has fallen to community organizations, such as Kindred Space in Los Angeles and the Urban Perinatal Education Center in Rhode Island (where I live!). So the easiest short-term thing to do is to support them. Please leave a comment to share any other organizations in your state that you know are doing this work.

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Looking for Memorial Day Weekend plans? Might be the perfect time to give potty training a shot. Potty training is notoriously difficult, and we unfortunately don’t have a lot of evidence-based guidance on what works best. So I asked the ParentData community to fill out a survey and share their knowledge — about 6,000 people responded.

👉Comment “Link” for a DM to an article that summarizes all of the best potty training advice we collected. 

Remember, you are not alone in the potty training struggle! It can be incredibly challenging, so please give yourself some grace.

#emilyoster #parentdata #pottytraining #pottytrainingtips #toddlertips

Looking for Memorial Day Weekend plans? Might be the perfect time to give potty training a shot. Potty training is notoriously difficult, and we unfortunately don’t have a lot of evidence-based guidance on what works best. So I asked the ParentData community to fill out a survey and share their knowledge — about 6,000 people responded.

👉Comment “Link” for a DM to an article that summarizes all of the best potty training advice we collected.

Remember, you are not alone in the potty training struggle! It can be incredibly challenging, so please give yourself some grace.

#emilyoster #parentdata #pottytraining #pottytrainingtips #toddlertips
...

We’re hiring an Associate Editor at ParentData! More details at my link in bio. Please share with the great writers and data-loving people in your network. 📊💻

We’re hiring an Associate Editor at ParentData! More details at my link in bio. Please share with the great writers and data-loving people in your network. 📊💻 ...

Do you brand things a certain way to get your kid to accept it? Like calling carrots “rabbit popsicles”? Or telling them to put on their “super speed socks” in the morning? Share your rebrands in the comments below! You never know who you might be helping out 👇

#emilyoster #funnytweets #relatabletweets #parentingjokes #kidssaythedarndestthings

Do you brand things a certain way to get your kid to accept it? Like calling carrots “rabbit popsicles”? Or telling them to put on their “super speed socks” in the morning? Share your rebrands in the comments below! You never know who you might be helping out 👇

#emilyoster #funnytweets #relatabletweets #parentingjokes #kidssaythedarndestthings
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Have you ever panic-googled a parenting question when everyone else is asleep? If so, you’re not alone. 

Today is the first episode of a new biweekly series on my podcast: Late-Night Panic Google. On these mini-episodes, you’ll hear from some familiar names about the questions keeping them up at night, and how data can help. First up: @claireholt!

Listen and subscribe to ParentData with Emily Oster in your favorite podcast app 🎧

#parentdata #emilyoster #claireholt #parentingstruggles #parentingtips #latenightpanicgoogle

Have you ever panic-googled a parenting question when everyone else is asleep? If so, you’re not alone.

Today is the first episode of a new biweekly series on my podcast: Late-Night Panic Google. On these mini-episodes, you’ll hear from some familiar names about the questions keeping them up at night, and how data can help. First up: @claireholt!

Listen and subscribe to ParentData with Emily Oster in your favorite podcast app 🎧

#parentdata #emilyoster #claireholt #parentingstruggles #parentingtips #latenightpanicgoogle
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Sun safety is a must for all ages, especially babies! Here are my tips for keeping your littlest ones protected in the sunshine:
☀️ Most importantly, limit their time out in hot weather. (They get hotter than you do!)
☀️ Keep them in the shade as much as possible when you’re out.
☀️ Long-sleeve but lightweight clothing is your friend, especially on the beach, where even in the shade you can get sunlight reflecting off different surfaces.
☀️ If you want to add a little sunscreen on their hands and feet? Go for it! But be mindful as baby skin tends to more prone to irritation.

Comment “Link” for a DM to an article on the data around sun and heat exposure for babies.

#sunsafety #babysunscreen #babyhealth #parentdata #emilyoster

Sun safety is a must for all ages, especially babies! Here are my tips for keeping your littlest ones protected in the sunshine:
☀️ Most importantly, limit their time out in hot weather. (They get hotter than you do!)
☀️ Keep them in the shade as much as possible when you’re out.
☀️ Long-sleeve but lightweight clothing is your friend, especially on the beach, where even in the shade you can get sunlight reflecting off different surfaces.
☀️ If you want to add a little sunscreen on their hands and feet? Go for it! But be mindful as baby skin tends to more prone to irritation.

Comment “Link” for a DM to an article on the data around sun and heat exposure for babies.

#sunsafety #babysunscreen #babyhealth #parentdata #emilyoster
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That’s why I’m asking you to post a story, photo, or reel this week with #MyUnexpectedStory and tag me. I’ll re-share as many as I can to amplify. Let’s fill our feeds with these important stories and lift each other up. Our voices can create change. And your story matters. 💙

#theunexpected #emilyoster #pregnancycomplications #pregnancystory

I’m calling on you today to share your story. I know that many of you have experienced complications during pregnancy, birth, or postpartum. It’s not something we want to talk about, but it’s important that we do. Not just for awareness, but to help people going through it feel a little less alone.

That’s why I’m asking you to post a story, photo, or reel this week with #MyUnexpectedStory and tag me. I’ll re-share as many as I can to amplify. Let’s fill our feeds with these important stories and lift each other up. Our voices can create change. And your story matters. 💙

#theunexpected #emilyoster #pregnancycomplications #pregnancystory
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OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio!

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio! ...

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio!

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio! ...

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio!

OUT NOW: My new book “The Unexpected: Navigating Pregnancy During and After Complications” is available on April 30th. All of my other books came out of my own experiences. I wrote them to answer questions I had, as a pregnant woman and then as a new parent. “The Unexpected” is a book not to answer my own questions but to answer yours. Specifically, to answer the thousands of questions I’ve gotten over the past decade from people whose pregnancies were more complicated than they had expected. This is for you. 💛 Order now at my link in bio! ...

Is side sleeping important during pregnancy? Comment “Link” for a DM to an article on whether sleep position affects pregnancy outcomes.

Being pregnant makes you tired, and as time goes by, it gets increasingly hard to get comfortable. You were probably instructed to sleep on your side and not your back, but it turns out that advice is not based on very good data.

We now have much better data on this, and the bulk of the evidence seems to reject the link between sleep position and stillbirth or other negative outcomes. So go ahead and get some sleep however you are most comfortable. 💤

Sources:
📖 #ExpectingBetter pp. 160-163
📈 Robert M. Silver et al., “Prospective Evaluation of Maternal Sleep Position Through 30 Weeks of Gestation and Adverse Pregnancy Outcomes,” Obstetrics and Gynecology 134, no. 4 (2019): 667–76. 

#emilyoster #pregnancy #pregnancytips #sleepingposition #pregnantlife

Is side sleeping important during pregnancy? Comment “Link” for a DM to an article on whether sleep position affects pregnancy outcomes.

Being pregnant makes you tired, and as time goes by, it gets increasingly hard to get comfortable. You were probably instructed to sleep on your side and not your back, but it turns out that advice is not based on very good data.

We now have much better data on this, and the bulk of the evidence seems to reject the link between sleep position and stillbirth or other negative outcomes. So go ahead and get some sleep however you are most comfortable. 💤

Sources:
📖 #ExpectingBetter pp. 160-163
📈 Robert M. Silver et al., “Prospective Evaluation of Maternal Sleep Position Through 30 Weeks of Gestation and Adverse Pregnancy Outcomes,” Obstetrics and Gynecology 134, no. 4 (2019): 667–76.

#emilyoster #pregnancy #pregnancytips #sleepingposition #pregnantlife
...

My new book, “The Unexpected: Navigating Pregnancy During and After Complications” is available for preorder at the link in my bio!

I co-wrote #TheUnexpected with my friend and maternal fetal medicine specialist, Dr. Nathan Fox. The unfortunate reality is that about half of pregnancies include complications such as preeclampsia, miscarriage, preterm birth, and postpartum depression. Because these are things not talked about enough, it can not only be an isolating experience, but it can also make treatment harder to access.

The book lays out the data on recurrence and delves into treatment options shown to lower risk for these conditions in subsequent pregnancies. It also guides you through how to have productive conversations and make shared decisions with your doctor. I hope none of you need this book, but if you do, it’ll be here for you 💛

#pregnancy #pregnancycomplications #pregnancyjourney #preeclampsiaawareness #postpartumjourney #emilyoster

My new book, “The Unexpected: Navigating Pregnancy During and After Complications” is available for preorder at the link in my bio!

I co-wrote #TheUnexpected with my friend and maternal fetal medicine specialist, Dr. Nathan Fox. The unfortunate reality is that about half of pregnancies include complications such as preeclampsia, miscarriage, preterm birth, and postpartum depression. Because these are things not talked about enough, it can not only be an isolating experience, but it can also make treatment harder to access.

The book lays out the data on recurrence and delves into treatment options shown to lower risk for these conditions in subsequent pregnancies. It also guides you through how to have productive conversations and make shared decisions with your doctor. I hope none of you need this book, but if you do, it’ll be here for you 💛

#pregnancy #pregnancycomplications #pregnancyjourney #preeclampsiaawareness #postpartumjourney #emilyoster
...

We are better writers than influencers, I promise. Thanks to our kids for filming our unboxing videos. People make this look way too easy. 

Only two weeks until our book “The Unexpected” is here! Preorder at the link in my bio. 💙

We are better writers than influencers, I promise. Thanks to our kids for filming our unboxing videos. People make this look way too easy.

Only two weeks until our book “The Unexpected” is here! Preorder at the link in my bio. 💙
...

Exciting news! We have new, high-quality data that says it’s safe to take Tylenol during pregnancy and there is no link between Tylenol exposure and neurodevelopmental issues in kids. Comment “Link” for a DM to an article exploring this groundbreaking study.

While doctors have long said Tylenol was safe, confusing studies, panic headlines, and even a lawsuit have continually stoked fears in parents. As a result, many pregnant women have chosen not to take it, even if it would help them.

This is why good data is so important! When we can trust the data, we can trust our choices. And this study shows there is no blame to be placed on pregnant women here. So if you have a migraine or fever, please take your Tylenol.

#tylenol #pregnancy #pregnancyhealth #pregnancytips #parentdata #emilyoster

Exciting news! We have new, high-quality data that says it’s safe to take Tylenol during pregnancy and there is no link between Tylenol exposure and neurodevelopmental issues in kids. Comment “Link” for a DM to an article exploring this groundbreaking study.

While doctors have long said Tylenol was safe, confusing studies, panic headlines, and even a lawsuit have continually stoked fears in parents. As a result, many pregnant women have chosen not to take it, even if it would help them.

This is why good data is so important! When we can trust the data, we can trust our choices. And this study shows there is no blame to be placed on pregnant women here. So if you have a migraine or fever, please take your Tylenol.

#tylenol #pregnancy #pregnancyhealth #pregnancytips #parentdata #emilyoster
...