How to avoid a Caesarean: take along a female friend for the additional support the father cannot provide
 By Jeremy Laurance

Allowing men into the delivery room has been one of the great social transformations of our time. Four out of five births are now attended by
the baby's father; but nobody has thought to ask whether their presence is enough.
Mothers are discovering the secret of a good birth is having another woman present. The loss of female support in childbirth  could lie behind the soaring Caesarean rate, which has doubled in 20 years.
A review of 15 research trials involving almost 13,000 women published in the Cochrane Library, the biggest source of evidence-based health care in
the world, has demonstrated a female supporter is the best guarantee of a natural birth. Mothers who had continuous support throughout labour from a woman trained to give it needed less pain relief, had fewer "operative" births - Caesareans or forceps deliveries - and had a more positive experience than those who received the normal attention of an often overworked midwife.

Professor Elaine Hodnett, of Toronto University, who ran the review, said the presence of a trained supporter who was not employed by the hospital and whose only loyalty was to the woman in her care was a "very powerful" element.

"My bottom line is women need and deserve close and continuous support in labour in an environment that is supportive. Many midwives will tell you they don't have the time to provide that. The key is the relationship the career has to the woman. The evidence showed if continuous support was provided by a nurse or midwife it was less effective," she said.

The idea is hardly new. Until 50 years ago, women typically gave birth supported by other women throughout labour, and had done so since the dawn of time. A mother, sister or neighbor would provide comfort and assist the woman through one of the most emotionally and physically demanding
experiences of her life.

But from the middle of the 20th century, as doctors assumed control of childbirth and it moved from home to hospital, the tradition of providing continuous support to women in labour was lost. Birth became technology driven. In place of the soothing presence of mother, sister or neighbor came the fetal monitor (to check the baby's heartbeat) with its blinking lights and nervy alarms.

The dehumanization of birth in the past half century has provoked one of the biggest protest movements in medicine. Women have sought to wrest control from the doctors and ensure labour and childbirth follow a natural course rather than one determined by technical requirements.

But it has been a losing battle. The rate of interventions in childbirth -involving induction of labour, anesthesia, forceps delivery or Caesarean - has risen inexorably. Figures published by the Department of Health in May 2003 showed that "normal" childbirth - without any intervention - has for the first time become a minority activity in Britain. Fewer than half of all new mothers - 45 per cent - now have a spontaneous labour and delivery.

The trend has not curbed the demand for natural childbirth and now women are learning that hiring a female supporter may be the most effective way of obtaining it. The idea of providing expectant mothers with a woman trained to support her has been imported from the US, where maternity care is even more technology-based and less woman-centered than in the UK. The female supporters are called "doulas" - from the Greek for "servant" - and there are an estimated 35,000 doulas assisting women in the US to challenge the technological tyranny of the medical birth. In Britain, there are only a few doulas practicing today but demand is rising.

Doulas are not medically qualified but they have training ranging from a few  days to nine months, depending on their previous experience. Importantly, they are hired by the woman, not the hospital, to support her through labour, provide encouragement and praise as well as coping techniques and to represent the mother's wishes to medical staff.

They bring the voice of experience to a situation which, for new mothers in particular, may seem frightening or threatening. And, rather than undermining the role of husbands and partners, they may turn out to support them too. Anecdotal evidence suggests men welcome the presence of someone with experience who relieves them of responsibility, eases their anxiety and helps them to play their part in the birth experience.

The cost of hiring a doula, and the need for the hirer to be the expectant mother and not the hospital or health service, puts them beyond the reach of most women. In North America, trials have been run with volunteer doulas whose services are offered to the neediest. "They have been successful - but it is a lot to ask," said Professor Hodnett.

Mary Newburn, the policy director at the National Childbirth Trust, said  the  Cochrane Review was "an absolute gem" and its findings "very important." She said: "It shows very clearly that one of the most effective things you can do to improve outcomes is provide women with continuous support during labour. It is extraordinarily effective in reducing Caesareans, the need for pain relief and even how mothers relate to their babies after birth. It is one of the few interventions with hard evidence to show its benefit."

That view was backed by obstetricians who did a study at Derriford Hospital, Plymouth in which 20 women were filmed throughout the course of their pregnancies and labours to record how many staff attended them and what they did. The number of staff who cared for the women ranged from three to 11 and the midwives were seen to be spending more time filling in forms than sitting with mothers and talking to them.

The study, led by Keith Greene, consultant gynecologist and director of perinatal research at the hospital, concluded the demands on midwives to provide technically exemplary care, record it meticulously and give emotional support all at the same time were incompatible. Loss of confidence in the care may have contributed to the rise in Caesareans, the study said.

 The researchers appealed for greater recognition for the doula, whose role in promoting a good birth now seems to be beyond doubt. In their  conclusion, they said: "It seems an irony that the most effective intervention, continuous female support in labour, receives little public support and low institutional priority, perhaps because it is not perceived as sophisticated enough, or too simplistic to merit a high profile."
 
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A substantive amendment to this systematic review was last made on 09 May 2003. Cochrane reviews are regularly checked and updated if necessary.

Background: Historically, women have been attended and supported by other women during labour. However, in recent decades in hospitals worldwide, continuous support during labour has become the exception rather than the routine. Concerns about the consequent dehumanization of women's birth experiences have led to calls for a return to continuous support by women for women during labour.

Objectives: Primary: to assess the effects, on mothers and their babies, of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies in the birth environment that may affect a woman's autonomy, freedom of movement, and ability to cope with labour; (2) whether the caregiver is a member of the staff of the institution; and (3) whether the continuous support begins early or later in labour.

Search strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register (30 January 2003) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2003).

Selection criteria: All published and unpublished randomized controlled trials comparing continuous support during labour with usual care.

Data collection and analysis: Standard methods of the Cochrane Collaboration Pregnancy and Childbirth Group were used. All authors participated in evaluation of methodological quality. Data extraction was undertaken independently by one author and a research assistant. Additional information was sought from the trial authors. Results are presented using relative risk for categorical data and weighted mean difference for continuous data.

Main results: Fifteen trials involving 12,791 women are included. Primary comparison: Women who had continuous intrapartum support were less likely to have intrapartum analgesia, operative birth, or to report dissatisfaction with their childbirth experiences. Subgroup analyses: In general, continuous intrapartum support was associated with greater benefits when the provider was not a member of the hospital staff, when it began early in labour, and in settings in which epidural analgesia was not routinely available.

Reviewers' conclusions: All women should have support throughout labour and birth.

Citation: Hodnett ED, Gates S, Hofmeyr G J, Sakala C. Continuous support for women during childbirth (Cochrane Review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley & Sons, Ltd.

 

This is an abstract of a regularly updated, systematic review prepared and maintained by the Cochrane Collaboration. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).

 

 

The Cochrane Library is designed and produced by Update Software Ltd, and published by John Wiley & Sons Ltd.