Women who receive continuous support during labour have reduced risk of caesarean, instrumental delivery or need for analgesia compared to usual care
- Midwifery Professorial Unit, La Trobe University/Mercy Hospital for Women, Heidelberg, Victoria, Australia
- Correspondence to: Dr Susan McDonald
Midwifery Professorial Unit, Mercy Hospital for Women, 163 Studley Rd, Heidelberg, VIC 3083, Australia;
Commentary on: Hodnett ED, Gates S, Hofmeyr GJ, et al. Continuous support for women during childbirth. Cochrane Database Syst Rev 2011;2:CD003766.
Implications for practice
Models of care supporting continuous support during labour were shown to be more likely to result in a spontaneous vaginal birth.
Women receiving continuous support required less analgesia and were less likely to report negative feelings about the birth experience.
Women receiving continuous support experienced shorter labours and their babies were less likely to have low 5-min Agpar scores. Therefore, such models of care should be considered for more extensive implementation in clinical practice settings.
Implications for nursing research
There is a need for further research in models of care which provide continuity of care and support to women during labour and birth.
Future studies should compare outcomes between different types of continuous support (eg, support provided by persons of the woman's choosing versus that provided by hospital staff) as well as the views of the people providing the support.
There is also a need to identify the cost for models of care where continuous support is available versus when it is not.
The studies included in this review were conducted in traditional hospital labour rooms with a mixture of obstetric nurse and midwifery staff who may or may not have been the primary care provider/decision maker. (Medical role or influence in outcomes was not reported.)
This review focuses on comparisons where women who have been allocated various combinations of support (eg, partner, previously unfamiliar support person, friend or close relative) during labour are compared to ‘routine care’ where a continuous support person may or may not be permitted in the birth room.
This study is a systematic review which includes 21 studies involving over 15 000 women.
The comparisons include: (1) policies about companions; (2) type of companion (partner, close friend or relative, previously unknown person); (3) availability of epidural analgesia and (4) routine use of external fetal monitoring and their effect on the primary outcomes of: (a) analgesia/anaesthesia, (b) synthetic oxytocin use in labour, (c) spontaneous vaginal birth, (d) postpartum depression(using a prespecified cut-off score on a validated instrument), (e) negative feelings about the birth experience, (f) admission of the baby to special care nursery and (g) breastfeeding 1–2 months postpartum.
Details are provided about the review process which included methodology used, a clearly described inclusion and exclusion criteria, search strategy, predetermined outcomes of interest and a thorough assessment for quality of the studies and risk of bias. Random-effects analyses were applied where high heterogeneity was present and results were reported using risk ratios for categorical data and means difference for continuous data. The review contains very useful graphical representations of the summaries for methodological quality for ease of reference.
The results unsurprisingly favour the experiences of women who have received continuous support. Interestingly, women rated more favourably care received from support persons previously unknown to them. The results also indicated that women who received one-to-one continuous support during labour were more likely to have a spontaneous vaginal birth, less analgesia and were less likely to report negative feelings about the birth experience which is in keeping with previous literature dating back as far as the mid-1990s.1–3
Continuous support for women during labour has altered over time. Traditionally, women have been cared for and supported by other women during childbirth. Post–World War II and the transfer of women and midwifery from community settings to hospitals for birth resulted in a change in care models that may have fractured this relationship of woman being with woman. There are now many models of care with midwives as primary providers of care in partnership with women, the aim being to maximise the birth experience with an emphasis on low-medical intervention, while recognising the importance of appropriate consultation and referral with other members of the healthcare team.
This study highlights the variability which may exist in access to and choice of support persons for women in labour in some birth settings and the need to accommodate and respect individual needs. Birth centre, team, group practice and caseload models of care have all been studied over the past 20 years and all provide evidence that a continuous relationship with midwives during pregnancy, labour and birth results in higher satisfaction and lower intervention rates including caesarean section.1–3
Perhaps a limitation of this review lies in the limited types of models of care and support available to the women in the timeframe most of trials included were conducted. It is now more uncommon for women to be unaccompanied in labour, particularly in western settings. Also in many of the trials in the review, nurses, rather than midwives appear to be the providers of care in labour. This perhaps reflects international differences about who provides care and therefore what decisions around care to women may be made during pregnancy and birth.
The review which has been conducted by an experienced and highly regarded systematic review team supports the need for continued research into what factors facilitate best practice outcomes for women and their families that reduce intervention where possible and encourage an environment where the woman feels well informed and well supported.