Source: Amorim MMR and Katz L. Continuous support for women during childbirth: RHL commentary (last revised: 1 May 2012). The WHO Reproductive Health Library; Geneva: World Health Organization.
Compared with usual care, the provision of continuous support to women during labour increases the likelihood of spontaneous vaginal birth, reduces the 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 mothers express more satisfaction with the birth experience.
RHL Commentary by Amorim MMR and Katz L
Historically, and across cultures, women have delivered at home and been attended and supported by other women during labour and delivery (1). However, the majority of women in many countries nowadays give birth in hospitals, where labour and delivery are regarded as medical events, with women in labour being treated as patients (2, 3). As a consequence, continuous intrapartum support received by women in the past is being lost (4, 5).
In recent years women and social movements, as well as health policy-makers, have called not only for making childbirth more natural, but also for continuous, one-to-one support by and for women during labour. In response to these calls, policy changes have occurred and the women’s partner, family members or friends are being allowed to participate in childbirth, even in institutional settings such as labour wards and delivery rooms (6). Those who advocate for the presence of family and friends during labour and childbirth claim that these people can provide continuous support during labour. On the other hand, some health-care professionals have questioned whether lay family or community members can indeed help labouring women in dealing with the pain and the anxiety related to childbirth (7). The present Cochrane Review (8) aimed to assess the effects of continuous, one-to-one intrapartum support compared with usual care.
2. Methods of the review
The review authors searched the Cochrane Pregnancy and Childbirth Group’s Trials Register for studies without placing any language restrictions. The selection criteria for including studies in the review were randomized controlled trials that had compared continuous labour support provided by either a familiar or an unfamiliar person (with or without health-care professional qualifications) with usual care. Participants in the studies were pregnant women in labour. In all cases ‘usual care’ did not involve continuous intrapartum support, but it could have involved other measures, such as routine epidural analgesia for pain relief in labour.
The primary maternal outcomes were any analgesia/anaesthesia (pain medication), synthetic oxytocin during labour, spontaneous vaginal birth, postpartum depression and negative rating of/negative feelings about the birth experience. The primary neonatal outcomes were admission to special care nursery and breastfeeding at 1–2 months postpartum. The secondary outcomes included labour events (regional analgesia/anaesthesia, duration of labour, severe labour pain), cesarean birth, instrumental vaginal birth, perineal trauma (episiotomy or laceration requiring suturing), low 5-minute Apgar score and prolonged newborn hospital stay, difficulty mothering, and low self-esteem in the postpartum period.
A fixed-effect Mantel-Haenszel meta-analysis was used for combining data and a random-effects analysis was adopted for comparisons in which there was high heterogeneity. In instances in which there was a high risk of bias associated with the quality of the included trials, sensitivity analyses was carried out for the primary outcomes. Subgroup analyses included policy regarding the presence of companion, availability of epidural analgesia, policy on routine electronic fetal monitoring and variations in provider characteristics.
3. Results of the review
A total of 21 trials involving 15061 women were included. The trials had been conducted under varying hospital conditions, regulations and routines. There was notable uniformity in the descriptions of continuous support across all trials, and in all of them the intervention included continuous or nearly continuous one-to-one support, at least during active labour. The review authors rated the quality of the trials as being generally good to excellent.
Nineteen out of 21 trials included specific mention of comforting touch and use of words of praise and encouragement by the support provider. In 11 trials the presence of the partner or other family members during labour was allowed, but in the other 10 trials no additional support was permitted. Epidural analgesia was routinely available in 14 trials and electronic fetal monitoring was used routinely in nine of them. It was not possible to compare the effects of continuous intrapartum support according to phase of labour (early versus active labour). The individuals providing continuous support varied in term of their childbirth caregiving experience, qualifications and relationship to the labouring women. They could be part of hospital staff (such as midwives, student midwives or nurses), or they could be other women or not members of the hospital staff, with or without special training (such as doulas or women who had given birth before).
Women allocated to continuous support were more likely to have spontaneous vaginal birth [relative risk (RR) 1.08, 95% confidence interval (CI) 1.04–1.12] and less likely to receive intrapartum analgesia (RR 0.90, 95% CI 0.84–0.97) or to report dissatisfaction (RR 0.69, 95% CI 0.59–0.79). In addition, they had shorter duration of labour (mean difference −0.58 hours, 95% CI −0.86 to −0.30), they were less likely to have caesarean section (RR 0.79, 95% CI 0.67–0.92) or instrumental vaginal birth (RR 0.90, 95% CI 0.84–0.96), regional analgesia (RR 0.93, 95% CI 0.88–0.99), or a baby with a low 5-minute Apgar score (RR 0.70, 95% CI 0.50–0.96). There was no apparent impact on other intrapartum interventions, such as the use of oxytocin, maternal problems (serious perineal trauma, severe labour pain, difficult mothering, low postpartum self-esteem and postpartum depression), other neonatal complications (admission to special care nursery and prolonged neonatal stay) or breastfeeding at 1–2 months postpartum.
Subgroup analyses suggested that continuous support was most effective when it was provided by a woman who was neither part of the hospital staff nor belonging to the woman’s social network. It was also most effective in settings in which epidural analgesia was not routinely available. It was not possible to conduct the planned subgroup comparison based on timing of the onset of labour support.
4.1. Applicability of the results
The benefits of continuous labour support in terms of maternal and perinatal outcomes are clear, as demonstrated by this Cochrane Review, and they are consistent across all trials in all settings, despite differences in obstetrical routines, hospital policies and conditions and qualifications of the individuals who provided the support. When continuous labour support is provided, women have more spontaneous vaginal birth, shorter duration of labour, less use of labour analgesia, fewer cesarean sections and instrumental deliveries and less babies with low 5-minute Apgar scores. Additionally, women express more satisfaction with birth experience.
Although it is virtually impossible to determine the “ideal” form of continuous intrapartum support, benefits seems to be the greatest when labour support is provided by a doula. Support provided by lay doulas is associated with reduced length of labour and higher 5-minute Apgar scores. On the other hand, any continuous non-staff caregiver (friends, family members or the baby’s father) can provide labour support with reduction in the use of labour analgesia and operative deliveries.
4.2. Implementation of the intervention
All hospitals should implement programmes that offer continuous support to women during labour. The presence of a companion of the woman’s own choice should be permitted and encouraged. An alternative to this may be to integrate “doulas” in maternity wards for the provision of continuous support to women during labour. Doulas are lay women who have received special training to provide non-medical support to women and families during labour, childbirth and the postpartum period (7, 9). Policy-makers and administrators should recognize that the best outcomes are achieved when continuous labour support is provided by non-staff providers, especially doulas. This is particularly important where policy-makers wish to reduce high cesarean rates in their hospitals or country.
The costs of doula services, where available, are usually passed on to the mother’s family. These costs could be a barrier to the provision of continuous support. Considering all the advantages and possible lower costs to the health system associated with the presence of a doula (less likelihood of caesareans sections and analgesia use), covering the cost of doula services should be considered by policy-makers. Programmes for training and accreditation of doulas should be available in all regions of the country. Courses and programmes can be offered by public hospitals and primary health services for training community doulas.
4.3. Implications for research
Now that the benefits of continuous intrapartum support in terms of short-term maternal and perinatal outcomes are well established, future studies should investigate the effects of continuous support during the postpartum period as well as its impact on long-term maternal and infant outcomes. These outcomes should include, but should not be restricted to, common causes of postpartum morbidity, such as urinary and faecal incontinence, dyspareunia, prolonged perineal pain and depression. Further research should also cover some possible advantages of continuous support, such as easier establishment of mother-baby bonding and long-term breastfeeding.
Studies comparing different models of training of providers for continuous labour support should be carried out, and comparisons of the role of community doulas or doulas services offered by hospital and private doulas could also be performed. All these studies should include economic analyses of costs and benefits.
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