A survey of doula-supported births in 2013 in the UK
This was first published in MIDIRS 2014 and reproduced here with the kind permission of Nurturing Birth
In 2008 a survey was carried out by Nurturing Birth (Goedkoop 2009) to compare data given by birth doulas with national NHS maternity statistics (The Information Centre 2009). The results supported previous research reported in the international medical press (Klaus et al 1993) stating that doulas reduced the length of labour, the need for anaesthesia, and the likelihood of caesarean or instrumental delivery, and greatly increased the breastfeeding rates at birth and six weeks postpartum.
According to Doula UK (http://doula.org.uk/content/what-doula), the largest not-for-profit organisation of doulas in the UK:
‘“Doula” [pronounced “doola”] is a Greek word meaning “woman servant or caregiver”. It now refers to an experienced woman who offers emotional and practical support to a woman (or couple) before, during and after childbirth. A doula believes in “mothering the mother” — enabling a woman to have the most satisfying and empowered time that she can during pregnancy, birth and the early days as a new mum. This type of support also helps the whole family to relax and enjoy the experience.’
In 2013 it was Nurturing Birth who made the decision to repeat the survey to ascertain whether there had been any changes to the role and scope of doulas in supporting women during pregnancy and birth.
Over a period of four weeks the survey was circulated to doulas who had taken a doula preparation course with Nurturing Birth, and it was publicised on the forums and private Facebook groups of doulas who are members of Doula UK and/or those who had taken a course approved by Doula UK. A total of 539 doulas were emailed and invited to take part in the survey. One hundred and seventeen responses were received, giving results for 608 births in the UK in 2013. The average number of births supported annually by doulas was 5.4.
Ethical approval was not sought in order to undertake the survey as participation was voluntary and Doula UK only used the contact details previously provided and sanctioned for contact by known, approved doulas.
A simple online SurveyMonkey format was utilised to ask the research questions. This method was chosen to ensure the survey was easy for all participants to use and not too time-consuming to complete. It was anticipated that the use of this data collection method would increase the chance of a greater number of respondents completing the survey than would normally be achieved by other methods, such as a postal survey.
The following set of questions was used:
- How many births did you attend in 2013?
- Of those births, how many underwent induction (by pessary/gel/propess, artificial rupture of membranes (ARM) or syntocinon)?
- Of those births, how many women had an epidural?
- Of those births, how many went to an instrumental delivery?
- How many women had had a previous caesarean section (CS)?
- How many women achieved a vaginal birth after caesarean (VBAC)?
- How many of the births ended in CS?
- How many women birthed at home?
- How many women initiated breastfeeding?
- How many of those women were exclusively breastfeeding six weeks after the birth?
Closed questions requiring only short numerical answers were employed as this fulfilled the requirements for the survey and again kept the study relatively simple.
According to NHS maternity statistics (HSCIC 2013), the caesarean section rate remained stable during 2012-13, at 25.5%, with a 0.5% increase from 2011–12. Of the 608 doula-supported births in our survey, 76 ended in CS — a 12.5% rate, with 58 out of the 76 women going on to achieve a successful VBAC (76.3%). It was a limitation of the survey that the doulas were not able to specify whether the CS were emergency or elective, but three doulas commented independently that the CS they supported were elective, two citing the following reasons: repeat CS due to pelvic abnormality and a mother suffering from vasa previa. It is extremely difficult to find accurate research around VBAC rates nationally, but according to Association for Improvements in the Maternity Services (AIMS), the rates of VBAC vary according to the reason for the original CS, from around 60% for those who had a baby in distress, or ‘failure to progress’, up to 85% for previous breech births (Lesley 2004).
A total of 108 women birthed successfully at home with the support of a doula. This home birth rate of 26.3% is an increase from the 19% reported in the 2008 doula survey results (where 735 births were analysed) (Goedkoop 2009). This compares extremely favourably with the 2.4% Office for National Statistics figure for England and Wales (ONS 2013). Results from the survey indicated that 85% of the women did not use an epidural, compared with no spinal anaesthesia in 37.1% women nationally (50.7% for spontanteous deliveries) (HSCIC 2013). Within the 15% who did have an epidural were at least two women given spinal block for CS, so the actual uptake of women requesting epidural pain relief was less than 15%.
According to NHS maternity statistics, the percentage of women going in to labour spontaneously in England in 2012–13 was 64% (HSCIC 2013). Of the doula results, 19.6% were induced. Compared to the doula results of 64 of 608 women (10.5%) having instrumental assistance at their birth, 12.8% women nationally were assisted instrumentally with either forceps or ventouse (HSCIC 2013).
Ninety six point four per cent of women who gave birth supported by a doula initiated breastfeeding, and of those 586 women, 477 were still exclusively feeding at six weeks — 81.4% (or 78.5% of the total number who gave birth). According to the Department of Health’s Indicators on breastfeeding: quarter 4 2012/13 report (DH 2013), the national breastfeeding initiation rate was 73.9%, and the prevalence of breastfeeding at 6-8 weeks for the same time period was 47.2%.
These results can be shown in the following table giving percentages of various labour/birth/feeding-related factors. Comparison is between data from England during the period from 2010–2013 and data from our doula survey from 2013. Significance of Z-tests comparing population proportions is given: ** indicates significance at the 5% level, * at the 10% level and NS indicates non-significance. Three sources of data were used for the English data. Percentages relating to induction, epidural, instrument use and CS were calculated using HSCIC (2013) maternity statistics; home births were calculated using the characteristics of birth (ONS 2013); breastfeeding initiation rates and exclusively breastfeeding rates at six weeks were calculated using the Department of Health’s Indicators on breastfeeding: quarter 4 2012/13 report (DH 2013). We were unable to find information regarding previous CS and VBAC rates from publicly available data. One potential limitation of the Z-test in this case is that the samples are not strictly speaking independent.
|Percentages for birth- and breastfeeding- related factors in England|
|National births2010-2013%||Doula-supported births2013%||Z-testSignificance|
|Initiation of breastfeeding||73.9||96||**|
|Breastfeeding exclusively at six weeks||47.2||78||**|
The table shows that for all outcomes where a comparison was possible, except induction and use of instruments, the doula-supported births resulted in statistically significant ‘better’ birth outcomes. Of particular interest are reduced rates of epidural use, CS and a much higher number of home births. Instrument use is only significant at the 10% level, whereas the rates of inductions are almost the same. More than three quarters of mothers who had doula-supported births were still breastfeeding exclusively at six weeks as compared to only 47.2% of those without doula support.
Encouraging results emerged from the study as follows:
- only 12.5% of births supported by doulas ended in CS, just under half the national rate of 25.5%
- 26.3% of women had a home birth with doula support, compared to the 2.4% national rate
- 22.5% more women initiated breastfeeding with a doula and 31.3% more women were still feeding at six weeks
- epidural uptake was less than 15%, compared to a 62.9% national average (49.3% spontaneous births).
If we compare these results with the Cochrane review on Continuous support for women during childbirth (Hodnett et al 2013), we see a similar picture. The primary objective of the review was to assess the effect of continuous intrapartum care during labour. Twenty-two trials involving 15,288 women met the criteria for the review and provided usable data. The researchers were able to look into what kind of continuous support made a significant difference, be that a midwife, doula or partner. The conclusions of the Cochrane review were that, with continuous support in labour, there was a:
- 31% decrease in use of pitocin (syntocinon)
- 28% decrease in CS
- 12% increase in the likelihood of spontaneous vaginal birth
- 34% decrease in the risk of being dissatisfied with the birth experience.
In all of these, the best results occurred when the woman had continuous support from a doula, rather than another birth partner.
Limitations of the study
Before drawing final conclusions from these results we have to acknowledge the limitations of the survey carried out. The low response rate can in part be attributed to several factors beyond the control of the researchers as indicated by the following:
- out-of- date email address
- women who trained are no longer working as doulas
- a large number of women on the mailing list have taken courses very recently and haven’t started working yet
- women who having done the course decide that it is not for them
- women only working as postnatal doulas.
A further limitation of the study is the number of responses in comparison to the national statistics, the lack of clarity around epidurals and spinal anaesthesia, the inability to select whether a CS was emergency or elective, the lack of information to explore how induction numbers, epidural uptake, instrumental assistance and caesarean rates correlated. We also do not have information about how many births were planned to take place at home and transferred to hospital, or whether the doula was the sole birth partner.
While these results appear to indicate that doula-supported births lead to better birth and breastfeeding outcomes, it would be premature to say that this is entirely due to the presence of a doula at the birth. Hiring a doula in itself indicates that a woman has thought about the birth and is likely to have researched the process and want a particular birth outcome more than an average woman. The rate of home births amongst women with doulas is a case in point. Women who want a home birth and hire a doula for support have already decided that they want to eschew the normal NHS hospital route either because they believe that home births are better for the mother–child dyad or because previous experience has led them to prefer a home environment. Similar comments can be made about VBAC, although lack of data at the national level means we can only speculate on this.
Recommendations for future research
Many of the doulas commented on the lack of questions relating to the postnatal period, therefore it would be of interest to explore the involvement of doulas in postnatal care. A further insight into this topical area would be a qualitative study exploring both the doula and the woman’s experience of supporting and being supported during pregnancy, birth and the postnatal period.
Sophie Brigstocke is a recognised birth and postnatal doula, based in Clapham, SW London. She is one of Doula UK’s experienced mentors for new doulas, as well as being a breastfeeding peer supporter and baby massage instructor. She is co-owner of Nurturing Birth Ltd, facilitating courses around the UK for anyone who wishes to become a birth and/or postnatal doula. Nurturing Birth also offers parents a Doula Directory to find a doula to support them through their pregnancy, birth and early parenting experience. For more information about Nurturing Birth, visit www.nurturingbirth.co.uk.
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Brigstocke S. MIDIRS Midwifery Digest, vol 24, no 2, pp 157-160
Original article. © MIDIRS 2014.