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This commentary is now outdated and has been replaced by a new commentary.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: Brown H. Continuous support for women during childbirth: RHL commentary (last revised: 17 October 2007). The WHO Reproductive Health Library; Geneva: World Health Organization.
RHL Commentary by Brown H
1. EVIDENCE SUMMARY
This Cochrane review (1) was updated in 2007 with the addition of a new large trial (2) and exclusion of another study. The review (containing 16 randomized controlled trials involving 13 391 women) evaluates the effects on women and their babies of continuous, one-to-one support during labour and childbirth compared with usual care. The review also aims to determine whether the effects of continuous support are affected by: (i) routine practices and policies in the birth environment that may affect a woman's autonomy, freedom of movement and ability to cope with labour; (ii) whether the support provider is a member of the staff of the institution; and (iii) whether the continuous support begins early or later in labour.
The trials included in the review were carried out in 11 countries, including four low-income countries (n=1487). The quality of these trials was adjudged by the authors to be between good and excellent. The new trial (2) included in the review was carried out in a high-income country but in a group of low-income women.
The main findings from the primary comparison, which considered 30 maternal and neonatal outcomes, showed that women who had continuous one–to–one support during childbirth were more likely to have a slightly shorter duration of labour without using analgesia or anaesthesia and a spontaneous vaginal delivery. In addition, the women were less likely to report being dissatisfied with their childbirth experience. No adverse effects were reported.
The first subgroup analysis considered the impact of variations in policies and practices in different institutions: whether women were permitted to have a support person of their choice; whether epidural analgesia was available; and whether electronic fetal monitoring was used. The main limitation of this analysis is that, for settings where women were permitted a support person of their choice and where epidural analgesia and electronic fetal monitoring were available, the number of trial participants was much greater than for settings where these facilities were not available. Overall, the analysis suggests that the benefits of support during childbirth may be greater in settings where epidural analgesia is not available.
Other subgroup analyses evaluated the effectiveness continuous support by type of support provider (health-care staff or non-staff) and timing of the onset of support (early or late in childbirth). This analysis suggests that the benefits of support during childbirth are greater when the support is provided by someone who is not a staff member and if the support starts early in childbirth.
Overall, in terms of primary outcomes, the conclusions remain essentially unchanged from the previous version of the review (3) and continue to demonstrate clearly that the benefit of continuous one–on–one support during childbirth.
2. RELEVANCE TO UNDER-RESOURCED SETTINGS
2.1. Magnitude of the problem
Conditions for women during childbirth in under-resourced settings have long been described as far from ideal (4). More recent evidence from South Africa suggests that over 80% of women are not permitted to have a companion with them during childbirth despite the previously described benefits of one–to-one continuous support (5).
2.2. Applicability of the results
The results of this Cochrane review are particularly relevant to countries where a high proportion of women deliver in hospitals. This is the case in many low- and middle-income countries where women have moved from delivering at home (where they were supported by other women in their community) to delivering in under-resourced busy hospitals or clinics; in such settings women end up spending a large portions of their time in childbirth alone (5). The updated review has again highlighted the benefits of continuous one–on–one support during childbirth, in particular in settings where epidural and electronic fetal monitoring are not available, which is often the case in hospitals in low-income settings.
2.3. Implementation of the intervention
Continuous one–to–one support has clear benefits, both in terms of making childbirth humane and improving clinical outcomes. Implementing this simple intervention may prove to be quite complicated in low-income settings: lack of resources (e.g. lack of midwives, limited physical space in the delivery area or lack of privacy for women during childbirth) and negative attitudes of staff towards the presence of outsiders in the labour are often significant obstacles (5). A recent publication (5) from South Africa describes some of the challenges experienced in that country in implementing and sustaining programmes that promote continuous support during childbirth. Lessons learnt from this experience have been incorporated into some international initiatives that aim to improve care for women during childbirth (6).
Only four of the 11 trials included in this review were conducted in low-income countries. Hence, the focus for future research should be on implementation of continuous one–to–one support, particularly in low- and middle-income countries where it is not already routine practice and where it has the potential for even greater benefit.
- 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 controlled trial of continuous support in labor by a lay doula. J Obstet Gynecol Neonatal Nurs 2006;35:456-64. Medline
- Hodnett ED, Gates S, Hofmeyr G J, Sakala. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2003; Issue 3. Art. No.: CD003766; DOI: 10.1002/14651858.CD003766.
- Fonn S, Xaba M, Tint K, Conco D, Varkey S. Maternal health services in South Africa during the 10th anniversary of the WHO 'Safe Motherhood' initiative. S Afr Med J 1998;88:697-702. Medline
- Brown H, Smith HJ, Hofmeyr GJ, Garner P. Promoting childbirth companions in South Africa: a randomised pilot study. BMC Med 2007;5:7. Medline
- Effective Care Research Unit and the Reproductive Health Research Unit. Better Births Initiative. The WHO Reproductive Health Library No. 5. Geneva: World Health Organization; 2002.
This document should be cited as: Brown H. Continuous support for women during childbirth: RHL commentary (last revised: 17 October 2007). The WHO Reproductive Health Library; Geneva: World Health Organization.