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Am Fam Physician. 2003;67(10):2071

to the editor: The evidence-based answer to the “Cochrane for Clinicians: Putting Prevention into Practice” department in the October 1, 2002 issue of American Family Physician1 stated that “continuous caregiver support during childbirth has a number of benefits with minimal to no risks.” The Cochrane Review2 and this abstract1 serve to trivialize the role of the baby's father during the birth process and the long-term impact that the father has on the family unit.

I would like to make four points concerning the methodology of this Cochrane Review. First, the study is not blinded, because the mother would have been aware of the “continuous caregiver's” presence. Second, some of the end points measured are extremely “soft,” and some of the studies used different end points. Third, “continuous caregiver support” was not defined and may have varied among the 14 studies. Fourth, the abstract states that “in one half of the trials in this review, husbands or partners were allowed to accompany women.” This would imply that in the other one half of the trials, husbands or partners were not allowed to accompany women, which is hardly a “baseline” situation for expectant parents. Not to allow a father to be involved in the birth of his child for the purposes of a study would appear to be unethical. Conversely, if the mothers and fathers agreed to this artificial circumstance then there is an obvious selection bias.

There was mention of improvement of four clinical parameters; however, no mention was made of a difference in the final clinical outcome relative to the health of the mother or the baby. One less dose of pain medication, a lower score on the 5-point Apgar scale, or “slight reduction in the length of labor,” while statistically significant, may not be clinically significant. The main point that is not included in the discussion is that the caregiver partly or entirely supplants the father.

The birth of a child is a unique, wonderful, emotional and, sometimes, trying experience. As such, it can be a supreme bonding experience for the parents. The memories and emotional bond created by this experience can make them a stronger couple and a stronger family. The inclusion of a third-party caregiver diminishes the opportunity for the couple to share one of life's truly unique and most precious moments.

If observation studies indicate ways to train the father to better support the mother during birth, then provide this training rather than replace the father. Whatever benefits, if any, that are provided by the presence of a “continuous caregiver” pales against the lost opportunity for the parents to share the experience of the birth of their child.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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