Thursday, January 24, 2008

What Does Evidenced-Based Maternity Care Organization Say About Labor Support

Childbirth connection was founded in 1918. They are a not-for-profit organization whose mission is to improve the quality of maternity care through research, education, advocacy and policy. They promote safe, effective and satisfying evidenced-based maternity care.

What is the bottom line about labor support?

Several systematic reviews summarizing many randomized controlled trials provide information about the effects of labor support by a trained or experienced woman. These studies have been carried out in many different countries in a variety of maternity care systems, with different types of labor support providers. They have involved women with different social backgrounds. Virtually all studies have found positive impact on the mother's emotional experience and/or her labor, without finding disadvantages. This claim probably cannot be made for any medical procedure, drug, or restriction used in labor management.

The most recent systematic review of continuous labor support is available in full right on this website, along with a brief overview of the review. It summarizes the experiences of nearly 13,000 women who participated in 15 randomized controlled trials.

The authors conclude:
Continuous support during labour should be the norm, rather than the exception. All women should be allowed and encouraged to have support people with them continuously during labour (Hodnett and colleagues 2004).

What factors most contribute to women's satisfaction in childbirth?

In considering whether to make arrangements for labor support, it may be helpful to consider results of research about satisfaction in childbirth. A systematic review of the best available research (Hodnett 2002) finds that the following four factors make the greatest contribution to women's satisfaction in childbirth:

• having good support from caregivers
• having a high-quality relationship with caregivers
• being involved in decision-making about care
• having better-than-expected experiences, or having high expectations.

Arranging for labor support may make a big difference in your satisfaction!

What is the best evidence about the benefits of continuous support during labor?

This largest and most recent systematic found that when compared to women who did not receive continuous support, those who received continuous support were:

• less likely to have an epidural or other "regional" analgesia
• less likely to use any type of pain medication (including narcotics)
• less likely to give birth by cesarean section
• less likely to give birth with vacuum extraction or forceps
• less likely to be dissatisfied with or give a negative rating to their childbirth experience (Hodnett and colleagues 2004).

What appears to influence the impact of labor support?

Various systematic reviews have looked at the impact of continuous labor support under different conditions.

Several reviews have found that the type of person providing the care appears to make a difference.
Labor support provided by caregivers who come to the labor setting expressly to provide this care appears to offer women more benefits than labor support provided by nurses or other clinical caregivers from that setting.
(Hodnett and colleagues 2004, Simkin and O'Hara 2002, Scott and colleagues 1999).

In the most recent and largest review, when compared to women who did not receive continuous support, those who received continuous labor support from someone present just for this purpose were

• 26% less likely to give birth by cesarean section
• 41% less likely to give birth with vacuum extraction or forceps
• 28% less likely to use any pain medications and
• 33% less likely to be dissatisfied with or negatively rate their birth experience (Hodnett and colleagues 2004).

The reviews identified several other factors that seem to make a difference. Benefits of continuous labor support appear to be greater when women receive it

• beginning earlier rather later in labor (Hodnett and colleagues 2004, Simkin and O'Hara 2002)
• in settings that do not allow them to bring companions of choice (versus settings that do allow husbands, friends, etc.) (Hodnett and colleagues 2004, Simkin and O'Hara 2002)
• in settings where epidural analgesia is not routine (versus settings where epidural is routine) (Hodnett and colleagues 2004).

These patterns suggest that the more labor support a woman receives and the better its quality, the greater is its favorable impact. Because of this, women who work with a trained doula in usual (non-study) conditions may experience even greater benefits than the studies show. Usual conditions include choosing a compatible labor companion, meeting with her during pregnancy to develop a relationship and discuss preferences and concerns, working together continuously from early labor onward, and - in many cases - having face-to-face and/or phone contact after the birth.

Hodnett ED. Pain and women's satisfaction with the experience of childbirth: a systematic review. American Journal of Obstetrics and Gynecology 186,5 (2002) S160-72.

Hodnett ED, Gates S, Hofmeyr G J, Sakala C. Continuous support for women during childbirth [PDF]. The Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.

Scott KD, Berkowitz G, and Klaus M. A comparison of intermittent and continuous support during labor: a meta-analysis. American Journal of Obstetrics and Gynecology 180,5 (1999) 1054-1059.

Simkin PP and O'Hara MA. Nonpharmacologic relief of pain during labor: systematic reviews of five methods. American Journal of Obstetrics and Gynecology 186,5 (2002) S131-59.


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