Review in JAMA Network Open Examines Where Doula Care May Improve Maternal and Infant Outcomes

A new systematic review conducted by a research team from UPMC and the University of Pittsburgh School of Medicine evaluated clinical trials evidence on the association between doula care and maternal and infant health outcomes. The review identified areas where evidence appears strongest but also highlights existing gaps in study design and implementation research, along with recommendations for researchers for future trial designs.

Published in JAMA Network Open, the review analyzed 22 published articles representing 21 unique interventions conducted between 2000 and early 2026. The review focused specifically on clinical and pilot trials rather than observational studies.

The study was led by Peyton Groves, MD, a recently graduated medical student at the University of Pittsburgh School of Medicine. Dr. Groves and colleagues conducted the research under the mentorship of senior author Maya I. Ragavan, MD, MPH, MS, associate professor, Division of General Academic Pediatrics. Dr. Ragavan also is associate professor, public health and clinical and translational science at the University of Pittsburgh.

Interest in doula care has expanded in recent years, alongside persistent concerns about rates of maternal morbidity and mortality in the general population in the United States compared to other countries, but also in minority populations where maternal and infant health outcomes are worse. Doulas provide emotional, informational, and physical support during pregnancy, labor, delivery, and the postpartum period. Doulas often serve as a consistent support presence across multiple stages of care during and after pregnancy.

“We know that maternal and infant outcomes in the United States remain suboptimal particularly in some underrepresented and minority populations, and there has been increasing interest in whether doulas may help address some of those inequities and disparities,” Dr Groves says. “At the same time, there had not been a systematic review focused specifically on clinical trial evidence, which is important when trying to better understand causal relationships and intervention effectiveness.”

Dr. Groves and colleagues study found the most consistent evidence for improvements in maternal anxiety, breastfeeding initiation, and postpartum follow-up with respect to doula care. Evidence for other outcomes, including cesarean delivery rates and pain management, was more heterogeneous across the studies they examined.

Evaluating Doula Care Across Different Clinical Settings

One of the challenges in interpreting the clinical trials and their findings was the broad range of doula models employed and the interventions that were tested by researchers.

Within the 21 clinical trials and studies analyzed by Dr. Groves and colleagues, some focused exclusively on labor and delivery support. Other studies included prenatal home visits, postpartum follow-up, breastfeeding support, or care during abortion procedures.

Most studies were hospital-based, but several incorporated data on community and hospital settings. Some doula programs provided support only during labor, while others extended across weeks or months before and after delivery. Training standards and intervention intensity also varied between the studies Dr. Groves and colleagues reviewed.

“We wanted to take a broader view of what doula care can look like,” Dr. Groves says. “Traditionally, doulas are often thought of only in the context of labor and delivery, but many of the interventions extended into prenatal and postpartum care, and some of the more compelling findings actually emerged outside of the delivery suite itself.”

The strongest evidence the team found was related to outcomes in maternal anxiety and involved studies evaluating anxiety during labor and delivery. Several trials demonstrated lower anxiety scores among participants who received doula support.

“Those studies were evaluating anxiety during the birthing process itself, where the doula is physically present and actively providing support,” Dr. Groves says. “That probably aligns more closely with what doulas are specifically trained to do in those settings.”

The review also identified consistent evidence supporting breastfeeding initiation. Multiple studies demonstrated higher rates of breastfeeding initiation among participants who received doula care. The evidence for longer-term breastfeeding duration was less consistent in the studies the team analyzed.

In addition, one recent randomized trial involving mothers with infants in the neonatal intensive care unit found improved postpartum follow-up and reduced missed postpartum care opportunities among participants supported by doulas.

Methodological Gaps in the Current Literature

Despite the positive findings of doula care relative to anxiety and breastfeeding initiation, Dr. Groves and colleagues study identified significant limitations in the current clinical trials evidence base for how doula care can affect or improve pregnancy and postpartum outcomes.

Only 13 studies reviewed included formal sample size calculations tied to primary outcomes. Many studies evaluated numerous secondary outcomes without being adequately powered to assess them individually.

Dr. Groves and the team also found variability in how doula interventions themselves were described. Nearly half of the studies included in the review did not clearly specify doula training methods or their certification standards.

Another important finding is the majority of studies focused on doula care during the labor and delivery period, with few on postpartum care. Doula care has the power to be incredibly helpful particularly in the immediate postpartum period; future studies should consider testing the impact of postpartum support.

Implementation details were frequently absent as well. Only one study reported the extent of participant engagement with doulas, including the number of prenatal and postpartum visits completed.

“That was one of the biggest issues we identified,” Dr. Groves says. “If researchers are evaluating doula interventions, it becomes important to clearly describe what the intervention actually involved, how doulas were trained, how much contact participants had with them, and how those programs functioned within the health care system or systems in which they were conducted.”

The review also highlights the limited use of implementation science frameworks in existing doula research. This gap represents an important next step in future research as health systems in the United States increasingly consider integrating doula programs into maternal care.

“There is already growing interest in doula care and increasing Medicaid coverage in some states,” Dr. Groves says. “Future research needs to move beyond asking only whether doulas improve specific outcomes and also examine how these programs can be implemented, standardized, and sustained in real-world clinical settings.”

The review also identified important gaps in representation across existing studies. Many interventions excluded patients with high-risk pregnancies or did not adequately include populations most affected by maternal health inequities.

“There is definitely a need for more studies that leverage doula care for pregnant people experiencing inequities or challenges during their pregnancy and postpartum period,” Dr. Groves says. “Our team is currently working on a clinical trial focused on how doula care can help support survivors of intimate partner violence prenatally and postpartum, which is common and has significant health impacts on pregnant people and their infants.”

Study Reference

Groves P, Williams H, Salter CL, et al. Doula Care and Health Outcomes: A Systematic Review. JAMA Netw Open. 2026; 9(4): e268416.