Continuous support for women during childbirth
This commentary is now outdated and has been replaced by a new commentary. It is included in RHL for archival purposes only. It may be cited as: Langer A. Continuous support for women during childbirth: RHL commentary (last revised: 5 September 2007). The WHO Reproductive Health Library; Geneva: World Health Organization.
RHL Commentary by Langer A
1. EVIDENCE SUMMARY
This Cochrane review (1) assesses the effects on mothers and their babies of continuous, one-on-one intrapartum support compared with usual care. It was updated in 2007 with the addition of a new large study (2) and now includes 16 randomized controlled trials involving 13 391 women. The new study lends further support to the previous conclusion that one-on-one support offered by a lay person or a professional (either accompanied or unaccompanied by a relative) to women during labour and delivery has a positive effect on medical interventions during labour and on mothers’ emotional well-being. However, the addition of the new large and rigorous trial has also contributed to a revision of some of the previous results. For example, according to the results of some individual trials and former meta-analyses, the duration of labour was decreased in women who received support during labour. But after adding the results of the new study to the review, this positive effect on duration of labour has disappeared.
The review authors developed a new protocol for this Cochrane review. Although the primary objective remained unchanged (i.e. to assess the effects on mothers and babies of continuous, one-on-one emotional support compared with usual care in any setting), secondary objectives were added to discriminate better the effects of support under different conditions. To this end, new subgroup analyses were conducted to assess the effects on mothers and their babies of routine practices (e.g. epidural anaesthesia and continuous fetal monitoring) and policies related to the birth environment that may affect the woman’s freedom of movement and ability to cope with labour. Other subgroup analyses assessed the effects of: whether companions chosen by the woman were present in the labour room; characteristics of the providers of labour support, whether the birth companions were employees of the health-care institution or non-staff members; type of training and experience of the support providers and their relationship with the woman; and timing of commencement of continuous support (i.e. whether the support began prior to the onset of active labour or later). In this version of the review, the authors expanded the discussion about possible mechanisms of action.
The trials included in the review were conducted mostly in high-income countries (Australia, Greece, Belgium, Canada, United Kingdom and USA), but also in low- and middle-income countries (Botswana, Guatemala, Mexico, and South Africa). The trials demonstrated that women who have continuous, one-on-one support are less likely to have regional or any analgesia/anaesthesia, operative vaginal birth and caesarean section (all these differences were statistically significant, although only marginally). In addition, they are also less likely to report dissatisfaction with the childbirth experience [relative risk (RR) =0.73; 95% confidence interval (CI) 0.65–0.83)] and more likely to have a spontaneous vaginal delivery. Four trials involving approximately 1000 women demonstrated that, compared with usual care, continuous support was not associated with decreased need for artificial oxytocin during labour, lower five-minute Apgar scores, fewer admissions of newborns to special care, fewer postpartum reports of severe labour pain, and reduced duration of labour. There remains little information about the effects of continuous labour support on mothers’ and babies’ health and well-being in the postpartum period.
The positive effects of support were, in general, stronger when: (i) other sources of support were not available; (ii) epidural anaesthesia was not routinely used; (ii) one-on-one support was provided by someone who was not an employee of the hospital and focused exclusively on supporting the woman; and (iv) provision of support started early in labour.
This review could not answer questions about the mechanisms by which settings with routine epidural analgesia limit the effectiveness of labour support, or about the reasons why support provided by non-staff members was generally more effective than support by institutional staff. The review provides evidence of a "dose–response" type of relationship between support and effectiveness: the stronger the support a woman receives, the sooner it starts and the longer it is provided for, the greater its effectives.
These results are particularly relevant for middle-income countries, where most women deliver in hospitals that provide highly "medicalized" delivery care and companions are not allowed to be present in the labour room. No negative effects of continuous support were found in any of the trials included in this review.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1 Magnitude of the problem
A woman delivering with no support and under a medicalized and de-humanized model of care is very common in hospitals in middle-income countries, particularly in Latin America and some countries in Asia. In those regions, this is the prevalent model of care in urban areas, where more than 70% of the population currently lives. Nowadays, in Mexico more than 90% of women living in large cities deliver in hospitals (3). Indicators that clearly point to the high level of medicalization of childbirth in these settings are very high rates of episiotomy and caesarean section (4, 5). This highly medicalized model of care can be characterized as one that promotes the use of unnecessary interventions, neglects women's emotional needs and contributes to a high overall cost of medical services.
2.2. Applicability of the results
The results of this Cochrane review are particularly relevant for countries where a high proportion of women deliver in hospitals, such as most Latin American countries and some countries in Asia and Africa. Its relevance becomes even more significant considering that this review shows that the positive effects of support are stronger when no other source of support is available and where epidural anaesthesia and electronic fetal monitoring are not used routinely – conditions that prevail in a large proportion of hospitals in middle-income countries. Effects are also stronger when support starts early in labour. Unfortunately, early start of support may not be feasible in crowded hospitals, where women are usually not admitted until dilation has progressed substantially. Also, support during labour would not be relevant in settings where home delivery is the norm, and where women face problems of access to health-care facilities and institutions face shortages of resources (both human and material).
2.3.Implementation of the intervention
Providing support to women in labour is essential from a humane point of view, and may achieve improvements in some pregnancy outcomes and in mothers’ emotional well-being. However, social support may not be the best strategy for reducing obstetric interventions in highly medicalized health institutions. Social support should complement other interventions focused on changing policies and providers’ preferences and practices. Where resources are limited and there are competing needs, interventions have to be compared in terms of their effectiveness and cost before being recommended as a routine practice.
In middle-income countries, barriers to implementing this intervention should be few. The costs involved in providing such support would not be too high, especially considering that lay persons are a more effective option than professionals as support providers. Such people would not need lengthy or complex training and their work would not interfere with routine service delivery. However, opposition from health professionals, who may disagree with the presence of non-professionals in the labour ward and who may complain about the ward being too crowded, may need to be overcome. A social support programme does not involve any sophisticated skills or technology.
Changes will need to be made to the training curricula of health-care professionals. Measures will also need to be introduced in health-care institutions to help change the attitudes of health-care professionals and work practices in favour of providing continuous support to women.
Further research on this issue should include: effects of continuous labour support on the health and well-being of mothers and babies in the post-partum period; large sound trials on the effect of implementation of continuous support in developing countries under routine conditions (busy hospitals, rigid routines characterized by high rates of medical and surgical procedures, low prevalence of breastfeeding); evaluation studies of cost–effectiveness of social support, compared with that of other priority interventions; and feasibility and acceptability studies that include in-depth qualitative techniques to learn more about women's and providers' perceptions about routine care and provision of social support, obstacles to adoption of such an intervention and strategies that would help to overcome them. Other morbidity outcomes such as urinary and faecal incontinence (i.e. effects of obstetric fistula), pain during intercourse and depression should be included in future trials in developing countries where these conditions are common.
Sources of support: The Population Council, Regional Office for Latin America and the Caribbean.
- Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2003; Issue 3. Art. No.: CD003766; DOI: 10.1002/14651858.CD003766.pub2.
- Campbell DA, Lake MF, Falk M, Backstrand JR. A randomized control trial of continuous support in labor by a lay doula. Journal of Obstetric, Gynecologic, and Neonatal Nursing 2006;35(4):456-64.
- Secretaría de Salud. Estadísticas hospitalarias. Mexico 2001.
- Althabe F, Belizán J, Bergel E. Episiotomy rates in primiparous women in Latin America: hospital based descriptive study. BMJ 2002;324:945-6.
- Langer A, Villar J. Promoting evidence based practice in maternal care would keep the knife away. BMJ 2002;324:928-9.
This document should be cited as: Langer A. Continuous support for women during childbirth: RHL commentary (last revised: 5 September 2007). The WHO Reproductive Health Library; Geneva: World Health Organization.