Continuous Support for Women During Childbirth


Download continuous support systematic review:

Background to this systematic review

Questions and outcomes examined in the continuous support review

Review results

Ongoing work to use review results to educate professionals, women and the media and to improve practice


Background to this systematic review

An updated systematic review of the effects of continuous labor support was published in The Cochrane Library in 2012, issue 10, and is available here. This review summarizes results of 22 randomized controlled trials that involved 15,288 women.

This review is descended from the first systematic review of controlled trial research of effects of labor support, which appeared in Effective Care in Pregnancy and Childbirth (1989). It has contributed to the development of policy statements and guidelines, legislation, and programs promoting continuous labor support in many countries throughout the world.

The most recent update incorporates six new randomized controlled trials, expands outcomes included in subgroup analyses, discriminates among three types of labor support companions in a subgroup analysis, and has been updated to reflect current methodologic guidelines.
    

Questions and outcomes examined in the continuous support review

The main objective ("main comparison") was to assess the effects, on mothers and their babies, of continuous one-to-one support during labor compared with usual care, in any setting.

Supportive care during labor does not include clinical care, and may involve helping women with physical comfort, providing emotional support, offering information, helping women communicate their wishes to caregivers, and engaging their spouses or partners, as desired by the couple.

The new review adhered to established Cochrane Collaboration procedures for limiting bias, including a thorough strategy for identifying relevant studies, eliminating relevant studies that are not methodologically adequate, and summarizing remaining "included studies" with meta-analysis when appropriate.

Subgroup analyses were planned to compare effects of continuous labor support in different birth environments, with different caregivers, and beginning at different times:
  • policies about companions of the women's own choice: whether women were permitted to be accompanied by companions of their own choosing
  • policies about epidural analgesia: whether epidural was or was not routinely available
  • policies about continuous electronic fetal monitoring (EFM): whether continuous EFM was or was not routine
  • types of caregiver: whether the caregiver was a member of the hospital staff (e.g., nurse, midwife or student midwife), was chosen by the woman from her social network (e.g., partner, spouse, other relative, friend), or was neither and was present solely to provide one-to-one continuous labor support
  • timing in the onset of continuous support: whether the support did or did not begin before active labor.

The review identified 17 outcomes of interest for the main comparison. Primary outcomes were as follows:


Mother:
  • any analgesia/anesthesia
  • synthetic oxytocin during labor
  • spontaneous vaginal birth
  • postpartum depression
  • negative rations of/negative feelings about the birth experience


Baby:

  • admission to special care nursery
  • breastfeeding at 1-2 months postpartum


Secondary outcomes were:

  • labor events (epidural analgesia, severe pain)
  • birth events (cesarean birth, instrumental vaginal birth, perineal trauma - episiotomy or laceration requiring suturing)
  • newborn events (low 5-minute Apgar score, prolonged newborn hospital stay)
  • immediate and longer-term maternal outcomes (difficulty mothering, low self-esteem in the postpartum period)

Pre-determined outcomes for subgroup analyses were: any analgesia/anesthesia, synthetic oxytocin during labor, spontaneous vaginal birth, cesarean birth, admission to special care nursery, and negative rating of the childbirth experience.

Review results

Numerous graphs available within the full Continuous Support For Women During Childbirth review (PDF) compare all data that were available from all included studies for the specified outcomes of interest. Overall, women who received continuous support were less likely than women who did not to:
  • have regional analgesia
  • have any analgesia/anesthesia 
  • give birth with vacuum extraction or forceps 
  • give birth by cesarean
  • have a baby with a low 5-minute Apgar score
  • report dissatisfaction or a negative rating of their experience.

Women receiving continuous support were more likely than those who did not to:
  • give birth spontaneously (that is, with neither cesarean nor vacuum extraction nor forceps)
  • have a shorter labor.

Overall, continuous support did not seem to impact:
  • use of synthetic oxytocin during labor
  • newborn admission to special care nursery
  • prolonged newborn hospital stay
  • breastfeeding at 1 to 2 months postpartum
  • postpartum depression
  • postpartum self-esteem
  • severe perineal trauma
  • severe labor pain

Data were not available to compare subgroups with onset of continuous support before and after active labor. Here are other subgroup analysis results:
  • policies about companions of the women's own choice: in settings in which women's companions of choice were not permitted, continuous support appeared to have a stronger impact on reducing any analgesia/anesthesia use and cesarean birth, and increasing spontaneous vaginal birth than in settings without such policies.
  • policies about epidural analgesia: in environments where epidural analgesia was not routinely available, continuous support appeared to have a stronger impact on increasing spontaneous vaginal birth and reducing cesarean birth, admission to a special care nursery, and dissatisfaction with the childbirth experience than in settings with routinely available epidural analgesia.
  • policies about continuous EFM: in environments where continuous EFM was not routine, continuous support appeared to have a stronger impact on increasing spontaneous vaginal birth and reducing use of analgesia/anesthesia than in settings where EFM was routine.
  • type of caregiver: continuous support appeared to have the greatest impact when the companion was neither on the hospital staff nor selected from the woman’s social network (e.g., when a doula or community member provides such care); in comparison with usual care, such care was associated with reduced synthetic oxytocin, cesarean section and dissatisfaction, and with increased spontaneous birth. Continuous support by a member of the hospital staff did not seem to impact cesarean section, spontaneous birth, or women's satisfaction, and may have increased use of synthetic oxytocin. Support by companions selected from the woman's social network (e.g., partner, spouse, other relative, friend) was associated with increased satisfaction, but did not seem to impact use of obstetric interventions.
The reviewers drew the following conclusions about implications for practice:

Continuous support during labour should be the norm, rather than the exception. Hospitals should permit and encourage women to have a companion of their choice during labour and birth, and hospitals should implement programs to offer continuous support during labour… In present maternity care environments, benefits of continuous support are likely to be greater with companions who are not hospital staff members than with members of the hospital staff … Given the clear benefits and absence of adverse effects of continuous labour support, policymakers should consider including it as a covered service for all women.

The reviewers drew the following conclusions about areas warranting further research:

  • settings: resource-constrained countries
  • outcomes: effects on mothers' and babies' health and well-being in the postpartum period, economic analysis of relative costs and benefits
  • models: comparison of effects of different models of providing continuous support.

Ongoing work to use review results to educate professionals, women and the media and to improve practice

Childbirth connection carried out media outreach to publicize results of this review and regularly collaborates with DONA International, a major organization for doulas, caregivers who provide support to women during labor and in the early postpartum period.  We collect and publicize data about women's knowledge of and experience with continuous support in our Listening to Mothers surveys. This website includes an in-depth Pregnancy Topic for childbearing women about the established benefits of continuous labor support, options for labor support companions, and strategies for arranging for labor support.

© 2013 Childbirth Connection. All rights reserved.

Childbirth Connection is a national not-for-profit organization founded in 1918 as Maternity Center Association. Our mission is to improve the quality of maternity care through research, education, advocacy and policy. Childbirth Connection promotes safe, effective and satisfying evidence-based maternity care and is a voice for the needs and interests of childbearing families.
Most recent page update: 3/12/2013