Role of doulas across the pregnancy care continuum on maternal and child health: a scoping review – Nature

Report on the Role of Doulas in Advancing Sustainable Development Goals for Maternal and Child Health

Executive Summary

This report synthesizes findings from a scoping review of 23 peer-reviewed articles (2000-2023) to evaluate the impact of doula support across the pregnancy care continuum. The analysis reveals that doula care is a critical intervention for improving maternal and child health outcomes, directly contributing to the achievement of several Sustainable Development Goals (SDGs), particularly SDG 3 (Good Health and Well-being), SDG 5 (Gender Equality), and SDG 10 (Reduced Inequalities). Key findings indicate that doula support is associated with reduced cesarean rates, fewer preterm births, decreased labor duration, and enhanced breastfeeding initiation. By providing continuous physical, emotional, and informational support, doulas empower women, address health disparities in vulnerable populations, and promote positive birth experiences, making their integration into standard healthcare a strategic imperative for global health equity.

Introduction: Doula Care as a Catalyst for SDG 3

Modern maternity care systems often fail to provide the continuous labor support that mothers expect and require, creating a critical gap that hinders progress toward global health targets. This deficit directly impacts SDG 3, which aims to ensure healthy lives and promote well-being for all. Doulas, as trained non-clinical birth workers, have emerged as an essential resource to bridge this gap. They provide comprehensive support throughout the prenatal, labor, and postpartum phases, which is fundamental to achieving key health objectives.

• Aligning with SDG Target 3.1: By improving birth outcomes and reducing the need for high-risk interventions, doula care contributes to the global effort to reduce the maternal mortality ratio.
• Supporting SDG Target 3.2: By promoting healthier pregnancies and positive neonatal outcomes, doulas help end preventable deaths of newborns and children under five.
• Advancing SDG 10: Community-based doulas, in particular, serve marginalized and underserved populations, playing a crucial role in reducing health inequalities and ensuring equitable access to care.

This report examines the evidence on doula practices to inform healthcare providers and policymakers on their role in creating a more equitable and effective maternal healthcare system aligned with the 2030 Agenda for Sustainable Development.

Analysis of Doula Impact on Health Outcomes and SDGs

The scoping review identified four primary areas where doula support generates significant positive impacts on maternal and child health, each corresponding to specific SDG targets.

1. Impact on Mode of Delivery and Maternal Health (SDG 3)

Evidence from 13 studies demonstrates a strong correlation between doula support and improved delivery outcomes. These findings are critical for advancing SDG 3 by promoting safer childbirth practices.

1. Reduction in Cesarean Rates: Nine studies reported that doula support significantly decreased the incidence of cesarean births, promoting vaginal deliveries and reducing the risks associated with major surgery. This directly supports safer childbirth and maternal well-being.
2. Promotion of Non-Instrumental Vaginal Births: Doula-supported mothers were more likely to have a non-instrumental vaginal birth, indicating a smoother and less intervention-heavy labor process.
3. Empowerment and Confidence: Qualitative data suggests doulas empower clients by normalizing the delivery process, which contributes to better physical and psychological outcomes.

While three studies showed mixed or negative results in specific high-risk or immigrant populations, the overwhelming evidence points to doulas as a positive factor in reducing medically unnecessary interventions.

2. Doula-Based Labor Support and Well-being (SDG 3 & SDG 5)

Doulas provide essential support during labor that enhances patient autonomy and reduces the need for medical interventions, thereby promoting both physical health (SDG 3) and the empowerment of women in their healthcare decisions (SDG 5).

• Labor Induction: Women with doula support were more likely to use nonmedical labor induction techniques and experienced shorter labor durations. Studies showed significantly lower usage of Pitocin (oxytocin) in doula-supported groups.
• Pain Management: Doula support was associated with a higher use of non-pharmacological pain relief methods and a reduced likelihood of requesting epidurals. This empowers women to have more control over their birthing experience.
• Hospital Stays: One study noted longer hospital stays for doula-supported women, suggesting a need for further research into postpartum care protocols in these contexts.

3. Contribution to Child Health Outcomes (SDG Target 3.2)

The positive impact of doula care extends to newborns, directly contributing to SDG Target 3.2, which aims to end preventable deaths of newborns and children under five.

1. Reduced Preterm Births: Five studies demonstrated a lower rate of preterm birth among mothers with doula support, a critical factor in reducing infant mortality and morbidity.
2. Healthier Birth Weights: Mothers without doula assistance were found to be four times more likely to have a low-birth-weight infant. Doula-supported programs consistently reported lower percentages of low birth weight.
3. Enhanced Breastfeeding Initiation: Eight studies confirmed that doula support positively influences breastfeeding. Mothers in doula programs were more likely to initiate breastfeeding, and some studies showed higher rates of sustained breastfeeding at six weeks postpartum. This is a key intervention for infant nutrition and immunity.

4. Support for Maternal Mental Health and Equity (SDG 3.4 & SDG 10)

Doula care provides vital mental and emotional support, addressing maternal well-being (SDG Target 3.4) and reducing health disparities for vulnerable populations (SDG 10).

• Mental Health: One study found that women receiving doula care had 57.5% lower odds of postpartum depression or anxiety, highlighting a crucial benefit for maternal mental well-being.
• Empowerment and Advocacy: Qualitative studies consistently reported that doulas foster trust, enhance self-esteem, and improve maternal confidence and decision-making abilities.
• Addressing Inequalities: Community-based doula programs have proven highly effective for women from low-socioeconomic communities, incarcerated women, and other marginalized groups. By providing culturally competent care and navigating systemic barriers, these programs directly advance SDG 10 (Reduced Inequalities).

Conclusion and Recommendations for Policy Integration

The evidence synthesized in this report confirms that doula care is a high-impact, person-centered intervention that advances multiple Sustainable Development Goals. Doulas improve physical health outcomes for mothers and infants, promote mental well-being, empower women, and reduce critical health inequalities.

To leverage these benefits and accelerate progress toward the 2030 Agenda, the following actions are recommended:

1. Integrate Doula Care into Standard Maternity Services: Healthcare systems should recognize doulas as an integral part of the maternity care team to ensure continuous support for all birthing persons.
2. Expand Public Funding and Reimbursement: Policymakers should expand Medicaid and other public funding mechanisms to cover doula services, ensuring equitable access for low-income and marginalized populations in line with SDG 10.
3. Prioritize Future Research: Further research should focus on long-term health outcomes, cost-effectiveness, and the impact of doulas on health behavior change to build a more robust evidence base for global policy adoption.

Investing in and expanding access to doula care is a strategic and evidence-based approach to improving maternal and child health, fostering gender equality, and building a more equitable world.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

The article on the impact of doula support across the pregnancy care continuum connects to several Sustainable Development Goals (SDGs). The analysis reveals links to the following goals:

1. SDG 3: Good Health and Well-being: This is the most prominent SDG addressed. The article’s core focus is on improving maternal and child health outcomes, which is central to SDG 3. It discusses reducing negative birth outcomes, enhancing mental well-being, and improving access to quality healthcare support.
2. SDG 2: Zero Hunger: The article connects to this goal through its discussion of nutrition for newborns. Specifically, it highlights how doula support can positively influence breastfeeding initiation and continuation, which is crucial for ending malnutrition in infants and ensuring they have a healthy start in life.
3. SDG 5: Gender Equality: The article touches upon themes of female empowerment and autonomy in healthcare settings. By providing advocacy and informational support, doulas help pregnant individuals make informed decisions about their bodies and birth experiences, which aligns with the broader goal of empowering women and ensuring their reproductive rights.
4. SDG 10: Reduced Inequalities: The article explicitly addresses health disparities by examining the impact of doula care on vulnerable and marginalized populations. It references studies focusing on “Medicaid recipients, Black and Latina women,” “socioeconomically disadvantaged backgrounds,” “incarcerated women,” and “migrant women,” demonstrating a clear connection to reducing health inequalities within and among countries.

2. What specific targets under those SDGs can be identified based on the article’s content?

Based on the issues discussed, several specific SDG targets can be identified:

• Under SDG 3 (Good Health and Well-being):
  • Target 3.1: By 2030, reduce the global maternal mortality ratio. The article supports this target by focusing on interventions that improve delivery outcomes, such as “reducing cesarean rates” and providing continuous labor support, which are critical strategies for preventing maternal deaths and complications.
  • Target 3.2: By 2030, end preventable deaths of newborns and children under 5 years of age. The article directly relates to this target by examining neonatal outcomes. It discusses the positive impact of doula support on “reducing… preterm births,” lowering the incidence of low birth weight (LBW), and potentially decreasing admissions to the Neonatal Intensive Care Unit (NICU).
  • Target 3.4: By 2030, reduce by one-third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being. The article connects to the mental health component of this target by citing a study that found women with doula care had “57.5% lower odds of postpartum depression/anxiety.”
  • Target 3.8: Achieve universal health coverage, including access to quality essential health-care services. The article’s discussion on “expanding doula access” and integrating them into standard care, particularly for underserved populations through programs like Medicaid, aligns with the goal of ensuring everyone has access to quality health services.
• Under SDG 2 (Zero Hunger):
  • Target 2.2: By 2030, end all forms of malnutrition. The article addresses this target by highlighting the role of doulas in “enhancing breastfeeding initiation.” One study noted that doula care was associated with a “high prevalence of breastfeeding at six weeks,” which is a key practice for preventing infant malnutrition.
• Under SDG 10 (Reduced Inequalities):
  • Target 10.2: By 2030, empower and promote the social, economic, and political inclusion of all. The article demonstrates a focus on this target by analyzing studies that provide doula support to marginalized groups, including “incarcerated women,” “adolescent births,” and “women from socioeconomically disadvantaged backgrounds,” thereby promoting their inclusion in quality maternal healthcare.
  • Target 10.3: Ensure equal opportunity and reduce inequalities of outcome. By investigating how doula support can improve birth outcomes for populations that traditionally face health disparities, such as low-income and minority women, the article directly addresses the need to reduce inequalities in health outcomes.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

Yes, the article mentions or implies several quantitative and qualitative indicators that can be used to measure progress towards the identified targets.

• For SDG Targets 3.1 and 3.2 (Maternal and Neonatal Health):
  • Cesarean section rate: The article frequently mentions this as a key outcome, stating that doula support improves delivery outcomes by “reducing cesarean rates.”
  • Preterm birth rate: This is explicitly mentioned as an indicator, with the article noting a “reduced rate of preterm birth” and citing studies where “approximately 5% of women gave birth before completing 37 weeks of gestation.”
  • Proportion of births with low birth weight (LBW): The article provides specific data, such as doula support being associated with a “low birth weight (LBW) … rate of merely 10%.”
  • Neonatal Intensive Care Unit (NICU) admission rate: This is used as a measure of child morbidity, with one study reporting that “5.6% were admitted to the neonatal intensive care unit.”
  • Stillbirth rate: The article mentions a study that “reported a total of 10 stillbirths, resulting in a fetal fatality rate of 5.27 per 1000 births,” which can be used as an indicator for neonatal mortality.
• For SDG Target 3.4 (Mental Health):
  • Prevalence of postpartum depression and anxiety: A specific metric is cited: “women who received doula care during pregnancy had 57.5% lower odds of postpartum depression/anxiety.”
• For SDG Target 2.2 (Nutrition):
  • Rate of breastfeeding initiation: The article provides data, such as “approximately 90% of adult participants who received doulas support initiated breastfeeding.”
  • Rate of continued breastfeeding: Progress can be measured by tracking breastfeeding duration, as implied by the finding of a “high prevalence of breastfeeding at six weeks postpartum.”
• For SDG Target 10.3 (Reduced Inequalities):
  • Health outcome data disaggregated by population group: The article’s focus on specific groups (e.g., Medicaid recipients, incarcerated women) implies the use of disaggregated data to track and compare outcomes like cesarean rates or preterm births between these groups and the general population, thereby measuring the reduction of health inequalities.

4. Table of SDGs, Targets, and Indicators

Source: nature.com