Only 5% of births occurred in hospitals in the 1900’s. The shift to hospital births began in the 20th century as a result of increased regulation and medical advances such as the use of antibiotics, oxytocin, and blood transfusions. Between the late 19th century and the mid-20th century there was a dramatic change in the obstetric care of women. More physicians, mostly men, in the late 19th century began dominating obstetric care and replacing midwives, who were mostly women. According to the National Institute of Health, a study was conducted finding that home births attended to by midwives during this time actually had the lowest maternal death rate and that approximately two-thirds of the maternal deaths that occurred in hospital were preventable. The causes of maternal death, in order of prevalence, were found to be puerperal sepsis, eclampsia, hemorrhage, and accidents. Mothers began once more relying on doulas for emotional support and physical support in labor. Doulas are able to advocate for patients rights and health equity further improving health outcomes and decrease maternal and fetal/ newborn mortality rates. Moreover, over time, acknowledgement of these risks resulted in changes in the practice of obstetrics and, along with scientific advancement such as the discovery of antibiotics in 1929, the maternal mortality rate declined to where it is today. In 1992, DONA International was founded and became the first organization to train and certify doulas.