Often cited as a reason for the effectiveness of Doula care, the Harsh Environment Theory proposes that the psychosocial environment has fundamental effects on women’s childbirth experience, and aspects of birth room design indirectly influence maternal and neonatal outcomes.

According to this theory, many pregnant women associate childbirth in a hospital with many unpleasant factors, including lack of privacy, painful examinations, needles, unsympathetic staff, and bright lights. These associations can lead to negative outcomes including longer labor and increased discomfort or medical interventions.

A Doula, as a trained birth companion that is familiar to the mother and is focused exclusively on making the mother more comfortable, can help mitigate the negative effects of the clinical environment.