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1a) The Association for Prenatal and Perinatal Psychology and

1b) Factors Influencing Positive Birth Experiences of First-Time Mothers, Lena Nilsson, Tina Thorsell, Elisabeth Hertfelt Wahn, and Anette Ekström, School of Life Sciences, University of Skövde, Sweden. Department of Obstetrics and Gynecology, Skaraborg Hospital Skövde, Sweden.

2a) European Perinatal Health Report:

  • Raises important questions about the effectiveness of national healthcare policies and the role of evidence in maternity care. Variations in obstetric practices raise questions about the role of scientific evidence in clinical decision making.

  • In addition to caesarean, other aspects of clinical practice also varied widely.

  • For example, episiotomy rates ranged from 5% to 70% of vaginal deliveries, yet current evidence does not support routine use of this procedure.

2b) Macfarlane AJ, Blondel B, Mohangoo AD, Cuttini M, Nijhuis J, Novak Z, Olafsdottir HS, Zeitlin J, the Euro-Peristat Scientific Committee. Wide differences in mode of delivery within Europe: risk-stratified analyses of aggregated routine data from the Euro-Peristat study. BJOG 2015; DOI: 10.1111/1471-0528.13284.

3. Surveillance de la santé périnatale au Luxembourg 2011-2012-2013: available on

4. World Health Organization. Appropriate technology for birth. Lancet 1985; 2 (8452): 436-7

5. World Health Organization: Entre Nous - Birth in Europe in the 21st century. Entre Nous No. 81, 2015 - Cesarean Section or Vaginal Delivery in the 21st Century

6. One of the basic needs of labouring women is to be protected against any sort of neocortical stimulation, i.e rational language. M. Odent:

"The positive effects of doula care have been found to be greater for women who were socially disadvantaged, low income, unmarried, primiparous, giving birth in a hospital without a companion, or had experienced language/cultural barriers. (Vonderheid, Kishi, Norr & Klima, 2011.)

7. Evidence for Birth Doulas:

a) It is clear that compared with usual care, the provision of continuous support to women during labour increases the likelihood of spontaneous vaginal birth, reduces duration of labour and use of analgesia and lowers the incidence of caesarean section and instrumental delivery. Moreover, less babies are born with a low 5-minute APGAR score and mother express more satisfaction with the birth experience.  Amorim , M., & Katz, L. (2012): Continuous Support for Women during Childbirth - RHL Commentary - World Health Organization (WHO) Reproductive Health Library. WHO Safe Childbirth Checklist and guide.

b) WHO/RHR/16.10 © World Health Organization 2016, Companion of choice during labour and childbirth for improved quality of care: “Allowing women to have a companion of choice during labour and childbirth can be a low-cost and effective intervention to improve the quality of maternity care.”

c) Baby-Friendly Hospital Initiative by WHO & Unicef: Global Criteria, Mother-friendly care: A review of the hospital policies (p39) indicates that they require mother-friendly labour and birthing practices and procedures including: Encouraging women to have companions of their choice to provide continuous physical and/or emotional support during labour and birth, as desired.

  • Note that Maternite Centre Hospitalier Emile Mayrisch CHEM, Esch-sur-Alzette is currently certified as “Hopital-Ami des bebes et Hopital-Ami des Meres” so in effect should comply with the guidelines as outlined in the global criteria for mother-friendly care #1: "Encourager les mères à se faire aider, physiquement et émotionnellement, par des personnes de leur choix, de façon continue pendant le travail et l’accouchement, si elles le désirent"

d) Continuous Support for Women During Childbirth, Hodnett, E. D., Gates, S, Hofmeyr, G. C., & Sakala, C. (2013). Cochrane Database of Systematic Reviews:10:CD003766 -  Modern obstetric care frequently subjects women to institutional routines, which may have adverse effects on the progress of labour. Supportive care during labour may involve emotional support, comfort measures, information and advocacy. These may enhance physiologic labour processes as well as women's feelings of control and competence, and thus reduce the need for obstetric intervention. The authors maintain that continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.

e) Impact of Doulas on Healthy Birth Outcomes: Kenneth J. Gruber, PhD, Susan H. Cupito, MA, Christina F. Dobson, MEd. The Journal of Perinatal Education, 22(1), 49–56. Expectant mothers matched with a doula had better birth outcomes. Doula-assisted mothers were four times less likely to have a low birth weight (LBW) baby, two times less likely to experience a birth complication involving themselves or their baby, and significantly more likely to initiate breastfeeding. Communication with and encouragement from a doula throughout the pregnancy may have increased the mother’s self-efficacy regarding her ability to impact her own pregnancy outcomes.

f) At, the following statistics were observed by women who had continuous support of a Doula:

  • 31% decrease in the use of synthetic oxytocin,

  • 28% decrease in the risk of C-section,

  • 12% increase in the likelihood of a spontaneous vaginal birth (without instrumental assistance),

  • 9% decrease in the use of any medications for pain relief,

  • 14% decrease in the risk of newborns being admitted to a special care nursery,

  • 34% decrease in the risk of being dissatisfied with the birth experience.


g)  Doula support compared with standard care: Meta-analysis of the effects on the rate of medical interventions during labour for low-risk women delivering at term. Jacqueline H. Fortier MSc Marshall Godwin MD MSc CCFP FCFP. Conclusion: Trained doulas help to reduce the odds of certain medical interventions during labour for low-risk women delivering at term.


h) Doula Care, Birth Outcomes, and Costs Among Medicaid Beneficiaries, Katy Backes KozhimannilPhD, MPA, Rachel R. HardemanMPH, Laura B. AttanasioBA, Cori Blauer-PetersonMPH, and Michelle O’BrienMD, MPH. Conclusions. State Medicaid programs should consider offering coverage for birth doulas to realize potential cost savings associated with reduced cesarean rates.

i) Potential benefits of increased access to doula support during childbirth. American Journal of Managed Care. Kozhimannil, K.B. et al. (2014) Conclusions: Women with doula support have lower odds of nonindicated cesareans than those who did not have a doula as well as those who desired but did not have doula support. Increasing awareness of doula care and access to support from a doula may facilitate decreases in nonindicated cesarean rates.

j) Continuous support for women during childbirth, Cochrane Database Syst Rev. 2017 Jul 6, Bohren MA1, Hofmeyr GJ, Sakala C, Fukuzawa RK, Cuthbert A: Continuous support during labour may improve outcomes for women and infants, including increased spontaneous vaginal birth, shorter duration of labour, and decreased caesarean birth, instrumental vaginal birth, use of any analgesia, use of regional analgesia, low five-minute Apgar score and negative feelings about childbirth experiences. We found no evidence of harms of continuous labour support.

k) After praise and encouragement: emotional support strategies used by birth doulas in the USA and Canada. Gilliland AL, CONCLUSIONS: emotional support by professional birth doulas is more complex and sophisticated than previously surmised. Mothers experienced these strategies as extremely meaningful and significant with their ability to cope and influencing the course of their labour. IMPLICATIONS FOR PRACTICE:  the doula's role in providing emotional support is distinct from the obstetric nurse and midwife. Professional doulas utilise intricate and complex emotional support skills when providing continuous support for women in labour. Application of these skills may provide an explanation for the positive 'doula effect' on obstetric and neonatal outcomes in certain settings.

l) How is a Doula different from a labor and delivery nurse? Barnett et al. 2008, Gagnon & Waghorn. 1996, McNieven et al., 1992, Gale et al. 2001.

8. What is a Doula:

A Doula is a trained, independent, non-medical professional, experienced and knowledgeable about childbirth supporting expectant families in their wishes for their own birth experience and recognizes that birth is something a woman will remember all her life. A Doula understands the birth process and is aware of the emotional needs of a woman in labour. She provides continuous supportive care during labour which may involve emotional support, physical comfort measures, information and advocacy.

9. Doulas around the world: 

The use of doula support is becoming more common for birthing mothers all around the world. It is clear that an increasing number of women are seeking to improve their chances of a physiological birth and wish to do so with the support of a birth doula. In addition to the United States, Doulas are increasingly utilized in several world leaders in maternity care including (but not limited to): France, Germany, United Kingdom, Canada, Australia, New Zealand, Netherlands, Norway and Sweden.

10. Art. 8 of the European Convention on Human Rights: 

“Everyone has the right to respect for his private and family life, his home and his correspondence.” 

Human Rights in explains:

“As the European Court of Human Rights has observed*:

‘The right concerning the decision to become a parent includes the right of choosing the circumstances of becoming a parent,’ and ‘the circumstances of giving birth incontestably form part of one’s private life.’

Recognition of the right to choose the circumstances of childbirth requires states to legitimize and support the full range of women’s birth choices.

The right to choose the circumstances of childbirth has implications for women’s right to support for vaginal birth.


Birthing women make decisions around childbirth in accordance with their personal needs.  Women’s needs and decisions around modesty and privacy during labor and birth, pain relief, medical assistance, and surgery are different because women are different.


Maternity care systems should be able to anticipate and support a diverse range of needs and choices around pregnancy and childbirth, and to support those needs with respect and non-judgment.  Respectful maternity care optimizes health for mother, baby, and community.”

* Ternovszky v. Hungary. Application number 67545/09). JUDGEMENT 14 December 2010

11. Loi du 24 juillet 2014 relative aux droits et obligations du patient, refer article 7 "Droit à l'assistance":

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