to the editor: In a letter to the editor¹ of American Family Physician, Dr. Richards responded to a Cochrane Review² of caregiver support for women during childbirth that was abstracted in American Family Physician.³ He makes several excellent points about the invaluable role that fathers can play in supporting mothers during labor. However, he has several misconceptions that warrant further clarification.

Dr. Richards expresses concern that the caregiver providing labor support “partly or entirely supplants the father,” thus diminishing the couple’s ability to share in the experience of childbirth. The Doulas of North America, a national certifying organization for labor support caregivers, states that the doula’s role is to “provide physical, emotional, and informational support to women and their partners during labor and birth.”⁴ The doula organization adds, “the doula is there in addition to, not instead of, the partner. Ideally, the doula and the partner make the perfect support team for the woman, complementing each other’s strengths.”

The doula is not intended to replace the supportive partner. Doula support can alleviate the anxiety of both parents by helping the father and other family members support the laboring mother. Dr. Richards states,“if observation studies indicate ways to train the father to better support the mother during birth, then provide this training rather than replace the father.”¹ Providing this training is exactly what intrapartum caregivers do.

Dr. Richards also misunderstands some of the details of the clinical trials included in the Cochrane review.² He comments that in one half of the trials evaluated, women’s partners were not allowed to be present for the delivery, raising a potential ethical dilemma of excluding fathers from their children’s birth for the purposes of a study. The trials included in the review were conducted in diverse locations, including North America, Europe, Central America, and Africa. Hospital policies differ internationally, and some of these hospitals did not admit fathers as a matter of policy. Therefore, not admitting these fathers was standard care where these trials were conducted, rather than a condition artificially induced by the investigators.

Dr. Richards criticizes the Cochrane review² for not defining “continuous caregiver support.” The review² included trials that compared usual care with “continuous labour support by either a familiar or unfamiliar professional (nurse or midwife) or lay person (paid or volunteer),” providing one-to-one support. Dr. Richards also comments on the lack of blinding in the trials. Although the majority of trials were not blinded, one trial attempted blinding, by using a “sham” doula who did not actually provide support for control patients.⁵ For many medical interventions, trials cannot be adequately blinded. However, this does not obviate the need for careful evaluation of such interventions in the context of a randomized clinical trial. Finally, although doulas have not been documented to improve final clinical outcomes for mothers or infants, reductions in pain, operative vaginal deliveries, and cesarean deliveries are far from trivial clinical outcomes. Family physicians who provide obstetric care should consider using doulas in the intrapartum care of their patients.