Continuous labor support offers benefits to mothers and babies, has no known downsides.

A new comprehensive study describing the experiences of nearly 13,000 women has found that women who receive supportive care from a companion throughout labor are more likely than women without such care to avoid cesarean birth and other major medical interventions and to be satisfied with their birth experience.

The study, "Continuous Support for Women During Childbirth," was carried out through the prestigious Cochrane Collaboration. This international organization prepares and keeps up to date rigorous "systematic reviews" of the highest quality research in many areas of health and medicine.

The researchers examined effects of continuous labor support by combining the weight of evidence from the best available studies. They limited their review to the gold standard study design known as a "randomized controlled trial" (RCT). Randomly assigning each participant to a study group, either with or without continuous labor support, makes the groups comparable, except for the impact of the support. Differences found with this approach are likely to be a true reflection of the effects of supportive care. The results of the new study are based on an impressive body of research, fifteen high-quality RCTs.

Overall, women who received continuous labor support were less likely to experience:

* Epidural or other regional analgesia 

* Any analgesia/anesthesia, including epidurals and opioids 

* Birth with vacuum extraction or forceps

* Birth by cesarean

* Dissatisfaction or a negative rating of their birth experience

The authors concluded that all women should have continuous support throughout labor and birth.

"Epidural analgesia, cesarean section, and birth by vacuum extraction or forceps are major interventions with the potential for adverse shortand longer-term effects on mothers and babies.

Continuous labor support is an important tool to help women avoid risks associated with these practices and to have a satisfying experience at this important time in their lives," said Carol Sakala, PHD, MSPH, Director of Programs at the Maternity Center Association (MCA). Dr. Sakala is a co-author of "Continuous Support for Women During Childbirth."

Impact Greater under Specific Conditions: Type of Caregiver Can Make a Big Difference

In addition to examining overall effects of continuous labor support, the new research examined effects of this care under different circumstances. A major finding is that the type of person providing care appears to make a difference in the impact of this care. Effects were stronger when the person was not a member of the hospital staff and was an outsider present only to provide one-to-one supportive care.

Compared to women without continuous support, those who had continuous support from nonhospital caregivers experienced impressive reductions in risk for major abdominal surgery, other interventions, and dissatisfaction. These women were:

* 26 percent less likely to give birth by cesarean section;

* 41 percent less likely to give birth with vacuum extraction or forceps;

* 28 percent less likely to use any analgesia or anesthesia; and,

* 36 percent less likely to be dissatisfied with or negatively rate their birth experience.

"The organization of care in modern maternity units--including shift changes, diverse staff responsibilities, and staff shortages--appears to limit the effectiveness of labor support provided by members of the hospital staff," said Ellen D. Hodnett, RN, PHD, and Professor, Faculty of Nursing, at the University of Toronto. Dr. Hodnett, the lead author of the Review, added, "Nonhospital caregivers may be able to give greater attention to the mothers' needs."

In addition to the importance of type of caregiver, the reviewers also found that continuous labor support was associated with greater benefits when it: began earlier in labor; was used in settings in which epidural analgesia was not routinely available; or was used in settings in which women were not permitted to be accompanied by companions of choice (such as a partner, friend, or family member). Nonetheless, women experienced benefits from labor support even when begun later, used in settings with routine epidural, and used in settings where other companions were permitted.

The new review was recently published in the third quarterly issue of The Cochrane Library and is available on the Maternity Center Association's website, in full and without charge (see page 13). The site also includes a detailed online guide to labor support for pregnant women (http://www.maternitywise.org/ mw/topics/laborsupport/).

Background

Historically, laboring women have been supported by other women. However, more recently in hospitals worldwide, continuous labor support has become the exception rather than the routine.

"Concerns about the dehumanization of women's birth experiences have led to calls for a return to continuous support for women during labor," said Dr. Hodnett. "These conditions include institutional routines, high rates of intervention, limits on women's autonomy and control, unfamiliar personnel, and lack of privacy," she explained.

Supportive care during labor and birth may include:

* helping women with physical comfort;

* providing emotional support;

* offering information;

* helping women communicate their wishes to caregivers; and

* engaging women's husbands or partners, as desired by the couple.

"Continuous support during labor may enhance normal labor processes and thus reduce use of obstetric interventions," said Dr. Sakala. "Continuous labor support is a remarkable element of maternity care that offers well-established benefits and has no known downsides," she added.

Leading options for continuous labor support in the U.S. include labor assistants/birth doulas, or trained labor support companions, and the assistance of a friend or family member who is invited to be present during labor and birth.

In 2002, MCA carried out Listening to Mothers, the first national U.S. survey of women's childbearing experiences. Just 5 percent of survey participants reported using doulas during labor. However, this type of caregiver received the highest ratings when compared to supportive care provided by other types of caregivers and members of the woman's social network: 71 percent of those who used a doula rated the quality of this care as "excellent." And 60 percent of the women who received support from a family member or friend rated it as "excellent."

Trained labor assistants/birth doulas are available in many communities throughout the United States. Typically, a woman (and her partner, if she has one) selects a labor assistant during pregnancy and meets with her to discuss the mother's goals, preferences, and concerns. In addition to continuous presence during labor, labor assistants typically provide face-to-face and/or telephone support in the early postpartum period. A growing number of U.S. hospitals are establishing labor assistant/birth doula programs, and hospitals typically permit women to be accompanied by one or more companions of choice.

Implications for Practice and Research

The authors of "Continuous Support for Women During Childbirth" conclude that continuous labor support should be the norm, rather than the exception. "The results of earlier reviews of continuous labor support prompted organizations in Canada, the UK and the USA to issue practice guidelines advocating continuous support," Dr. Hodnett commented. "The results of the new review offer additional information that can be used to both reinforce and update policies and guidelines in this area," she concluded.

The Reviewers note that we need more research to understand the effects of continuous labor support on mothers' and babies' health and well-being in the postpartum period (including maternal depression), and the relative effects of different models of labor support, including care provided by trained labor assistants/birth doulas and by a relative or friend. They also recommend that future trials include economic analysis of the relative costs and benefits of continuous labor support.

About the Maternity Center Association

MCA is a not-for-profit organization that promotes safe, effective, and satisfying maternity care for all women and their families through research, education, and advocacy. Since 1918, MCA has identified and demonstrated a series of innovations to improve the quality of maternity care. MCA established its ongoing Labor Support Initiative in 2000 to promote increased access to labor support. Several key resources from this Initiative are available online, including:

Full text, and an overview, of the new Cochrane Review, "Continuous Support for Women During Childbirth," at: http://www.maternitywise.org/ prof/laborsupport/.

"Listening to Mothers" survey results, new national information about women's experience of labor support and other aspects of childbearing from the first national U.S. survey of childbearing women, which MCA carried out in 2002, at: http://www.maternity wise.org/listeningtomothers/.

"How Will I Get the Labor Support I Need?," a detailed online guide to help pregnant women understand benefits of labor support, options for labor support, and how to make arrangements for this care, at: http://www. maternitywise.org/mw/topics/ laborsupport/.

"Women Supporting Women During Childbirth," a printed brochure to help women understand and arrange for labor support, which is available through MCA's online bookstore at: http://www.maternitywise.org/ bookstore/.

--Maternity Center Association, September, 2003