Caregiver Support for Women During Childbirth: Does the Presence of a Labor-Support Person Affect Maternal-Child Outcomes?

JULIE SCOTT TAYLOR, M.D., M.Sc., Brown University Medical School, Pawtucket, Rhode Island

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied by an interpretation that will help clinicians put evidence into practice. Julie Scott Taylor, M.D., M.Sc., presents a clinical scenario and question based on the Cochrane Abstract, along with the evidence-based answer and a full critique of the abstract.

Clinical Scenario

A 23-year-old gravida 1, para 0 woman who is 32 weeks pregnant is being followed for uncomplicated prenatal care. At her next routine visit, you intend to discuss her labor plans, including who will be with her during labor and delivery.

Clinical Question

Should we recommend that pregnant women have an experienced female support person with them during labor and delivery?

Evidence-Based Answer

This review indicates that continuous caregiver support during childbirth has a number of benefits with minimal to no risks. It was less likely that women would need pain medications or have an operative vaginal delivery, a cesarean section, or a five-minute Apgar score of less than 7 when they had an experienced female caregiver--either a professional (nurse, midwife, or childbirth educator) or a nonprofessional (friend or family member who had given birth before or a doula)--with them continuously during labor and delivery. Benefits were independent of whether the patient's husband or partner was also present.

Cochrane Abstract Background. Social support can include advice or information, tangible assistance, and emotional support. Objectives. The objective of this review was to assess the effects of continuous support during labor and delivery (provided by health care workers or lay people) on mothers and babies. Search Strategy. The author searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. Selection Criteria. The author included randomized trials comparing continuous support during labor with usual care. Data Collection and Analysis. Trial quality was assessed. Study authors were contacted for additional information. Primary Results. Fourteen trials, involving more than 5,000 women, are included in the review.1 The continuous presence of a support person reduced the likelihood of medication for pain relief (odds ratio [OR] 0.71, 95 percent confidence interval [CI], 0.62, 0.81); operative vaginal delivery (OR 0.77, 95 percent CI, 0.65, 0.90); cesarean delivery (OR 0.77, 95 percent CI, 0.64, 0.91), and a five-minute Apgar score of less than 7 (OR 0.50, 95 percent CI, 0.28, 0.87). Continuous support also was associated with a slight reduction in the length of labor. Six trials evaluated the effect of support on mothers' views of their childbirth experience; although the trials used different measures (overall satisfaction, failure to cope well during labor, finding labor to be worse than expected, and the level of personal control during childbirth), in each trial the results favored the group that had received continuous support. Reviewers' Conclusions. Continuous support from professional health care workers or nonprofessional caregivers during labor and delivery has a number of medical and psychosocial benefits for mothers and their babies, and there does not appear to be any harmful effect. These summaries have been derived from Cochrane reviews published in the Cochrane Database of Systematic Reviews in The Cochrane Library. Their content has, as far as possible, been checked with the authors of the original reviews, but the summaries should not be regarded as an official product of the Cochrane Collaboration; minor editing changes have been made to the text (www.cochrane.org).

Cochrane Critique

Did the author address a focused clinical question? Yes.

Were the criteria used to select articles for inclusion appropriate? Yes.

Is it likely that important relevant articles were missed? No.

Was the validity of the individual articles appraised? Yes.

Were the assessments of studies reproducible? Yes.

Reading the Numbers This review includes only randomized controlled trials (RCTs). In this study format, patients are randomly allocated to either the treatment group (continuous labor support) or the control group (usual care). One of the most powerful aspects of an RCT is that it equally distributes confounding, which is the mixing of the treatment effect and other effects. With equal distribution of both known and unknown confounders, the differences between the treatment and the control groups should represent the effect of only the intervention. In reality, patients sometimes are assigned to one group but end up receiving care as if they were in the other group. Once a trial is complete, researchers must decide to analyze the data based on either "intent-to-treat"--the original allocation--or "treatment received"--the actual allocation. In this review, all data were analyzed based on the principle of intent-to-treat. With intent-to-treat analyses, estimates of treatment effects can be biased by misclassification because received treatment is misclassified as assigned treatment. However, treatment-received analyses can suffer from confounding, because that original equal distribution of known and unknown confounders is lost. Therefore, most RCT analyses, particularly those studying a complicated and multifactorial process such as childbirth, should be based on intent-to-treat.2

Were the results similar from study to study? Yes. Trials were conducted in 10 countries under widely disparate conditions, regulations, and routines. In every trial, the results either favored the group that had received continuous support or were neutral, depending on the specific outcome.

Can the results be applied to patient care? Yes.

Do the conclusions make clinical and biological sense? Yes.

Are the benefits of caregiver support during labor worth the harms and costs? Yes. With respect to harm, the known benefits make the intervention worthwhile because there are no known harms associated with labor support. With respect to cost, if the caregiver is a nonprofessional (doula, friend, or family member), there are benefits and no cost. If the caregiver is a professional (nurse, midwife, or childbirth educator), there are benefits and, frequently, but not always, costs. No studies have been done yet to evaluate whether continuous one-on-one support by a paid professional caregiver is cost-effective.

Practice Pointers

Women have widely different expectations about childbirth, and a woman is likely to feel very strongly about whom she would like to have with her (or not have with her) during labor and delivery. Of note, every caregiver in all of the studies included in this review shared two characteristics: they were female and they were experienced, because they had either given birth themselves or had medical training. The impact of male caregivers is not addressed here. In one half of the trials in this review, husbands or partners were allowed to accompany women. Women benefited from having an experienced female support person with them, regardless of whether hospital policy also allowed husbands or partners to accompany them in labor.

Few interventions in medicine provide such impressive benefits at such low cost and risk. Therefore, it is important to discuss the issue of a female labor-support person as part of routine prenatal care and to document the patient's plans in the medical record. The support person should be present continuously or nearly continuously during active labor and delivery to offer comforting touch and provide words of praise and encouragement.

As family physicians, we should understand and inform our patients in advance about general hospital policies on this issue (whether support people are allowed and, if so, how many; is there a lower age limit for support people, etc.). Other questions include the role of the nursing staff in the hospital and whether they can realistically function as a continuous support person in light of their other responsibilities. We also should be aware of alternative sources of support personnel, such as local doulas or training programs for medical students or midwives.

REFERENCES

1. Hodnett ED. Caregiver support for women during childbirth (Cochrane Review). Cochrane Database Syst Rev 2002;1: CD000199.
2. Rothman KJ, Sander G. Modern epidemiology. Philadelphia: Lippincott-Raven, 1998.

Julie Scott Taylor, M.D., M.Sc., is assistant professor of family medicine and director of predoctoral education at Brown University Medical School, Pawtucket, R.I.

Address correspondence to Julie Scott Taylor, M.D., M.Sc., Department of Family Medicine, Memorial Hospital of Rhode Island, 111 Brewster St., Pawtucket, RI 02860 (e-mail: julie_taylor@brown.edu). Reprints are not available from the author.