In this blog for midwives, Meghan Bohren (Lecturer in Gender and Women’s Health at the University of Melbourne) revisits the latest Cochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. More on continuous support for women during labour and childbirth and reflects on what can affect the implementation of labour companionship. This blog is part of a series called ‘Maternity Matters’.
Continuous support for women during labour and childbirth is recommended by the World Health Organization, and there is good evidence that there are several benefits for both the woman and baby. However, not all women benefit from support, and may go through labour and birth in a hospital without a trusted family member, spouse/partner, or friend.
I have previously blogged about how supporting women throughout labour and childbirth is both effective and equitable. In this blog, I provide an overview of the health benefits of labour companionship, and dive deeper into the evidence from two Cochrane Reviews to explore factors affecting implementation of labour companionship.
Positive benefits for women’s and babies’ health
In 2017, we explored the effect of women having continuous support during childbirth, by updating this Cochrane Review. We found 26 relevant studies (randomised trials) from 17 countries involving over 15,000 women. We defined “continuous” support as support provided from at least early labour (or within one hour of hospital admission), through until at least the birth, and provided by a person whose sole responsibility is to provide support to the woman. Continuous support was provided by a woman’s partner, family member, or friend; hospital staff (student midwives); or a doula (a trained birth companion who is a non-medical professional).
We found that women who receive continuous support may be more likely to give birth vaginally, rather than by caesarean section, and without the need for instruments such as forceps to help her give birth. They may be less likely to use pain medications, and may be more likely to be satisfied and have shorter labours. The babies of women who received continuous support may be less likely to have low five-minute Apgar scores (the score used when babies’ health and well-being are assessed at birth and shortly afterwards). We did not identify any harms.
Learning from experiences of labour companionship
After understanding the positive effects of continuous support, we sought to understand how women, families and health workers experience labour companionship, and why this type of support is not available for all women across the world. To answer these questions, we conducted a new Cochrane Review looking for qualitative studies, which explore women’s, their family members’, healthcare providers’ and doulas’ perceptions and experiences of labour companionship. We found 51 qualitative studies from 22 countries. We had high or moderate confidence in many of our findings. Where we only had low or very low confidence in a finding, we have indicated this below.
We found that companions supported women in a few different ways. This includes helping to bridge communication gaps between the woman and her health workers and speaking up in support of the woman’s wishes. We also found that companions provided more practical and emotional support, such as encouraging the woman to move around, holding the woman’s hand and building her confidence through reassurance and praise.
So why don’t all women have support from a lay companion?
Most healthcare providers believed that having a lay companion (spouse/partner, family member, friend) support a woman throughout labour and childbirth was beneficial to the woman and worked well when companions were integrated into the model of care. However, when lay companions were not well engaged or integrated, conflict could arise as they may be perceived as an additional burden for healthcare providers to manage their presence, and provide ongoing direction and support.
The benefits are sometimes not recognised
Some women weren’t always able to have a companion during labour, and this may be for several reasons. First, health workers and women did not always recognise the benefits of companionship. Some providers viewed companionship as a low priority or less important compared to other aspects of care, and therefore deprioritised companionship due to limited resources. Some women and their partners believed that partners or family members were unable to do anything to help the woman during labour, or that she could persevere without their support. When some women learned about the type of tasks that companions could help with (holding her hand, rubbing her back, encouraging her), they believed that this was already the role of the clinical staff and that companions therefore could not provide any additional benefit.
Physical space constraints on the labour ward were key barriers, as it was perceived that privacy could not be maintained and wards would become overcrowded. Many health facilities, particularly in lower resource settings, have open floor plans for their labour and delivery wards, with multiple beds in the same room. Curtains may be the only possible privacy measure, and may not be available or consistently used. In this type of setting, women may only be allowed to have a female companion, in order to maintain the privacy of other women in labour.
Some providers, women and their partners were concerned that the presence of a labour companion may increase the risk of infection in the labour room (low confidence).
Gaps between policy and practice
Where policies theoretically allowed companions to support women, addressing gaps between policy and practice were thought to be important to ensure that women were actually allowed a companion (low confidence). For example, in Brazil, by law all women should be allowed companionship, but some healthcare providers may not allow the woman to have a companion present. This may be because of adequate insurance, if the companion appears unprepared, or because of a fear of being “supervised” by the companion (Bruggemann 2014).
Potential for conflict
Some providers were resistant to or not well trained on how to use companions, and this could lead to conflict. They felt that lay companions lacked a clear purpose and boundaries, may increase provider workload, and could be in the way of the providers. Some providers also were concerned that they would be evaluated unfairly by companions who did not understand the physiology of birth and the potential need for interventions. In contexts where there is a more technocratic or less woman-centred model of maternity care, women’s needs (including companionship) may be deprioritised in lieu of institutional routines, further exacerbating a potential point of conflict.
Lay companions (such as spouses/partners, family members, or friends) were often not integrated into antenatal care, which may cause frustration by all parties (low confidence). Where male partners in particular were included in antenatal preparation, they felt that they learned comfort and support measures to assist their partners, but that these measures were often challenging to implement throughout the duration of labour and birth.
Where do doulas fit in to support women?
We were also interested to explore how doulas may fit in to support women. Doulas are trained, non-medical professionals who provide continuous physical, emotional, and informational support to a woman before, during and after childbirth to help her have the best birth experience possible. Doula use is increasingly common in some higher resource settings such as the United Kingdom and the United States.
Women valued that doulas helped them to feel in control during labour and that their confidence was boosted by their support. They felt that doulas helped to explain in simpler language about how their labour was progressing, and could more clearly communicate the relationship between the passage of time, cervical dilation, pain tolerance and birth experiences.
Collaborative or conflicting roles?
Midwives believed that doulas played a collaborative role in supporting women during childbirth, and were assets to the team who provided more woman-centred, needs-led support (low confidence). Some healthcare providers felt that doulas could potentially address shortcomings in maternity services, for example by providing culturally competent and supportive care, and by enhancing continuity of care.
However, some midwives found it difficult to engage as carers when doulas were present, as they felt that doulas encroached on their carer role. This role conflict was exacerbated when doulas provided medical advice, which midwives felt was inappropriate given their training. Furthermore, some doulas were viewed as being “anti-medical establishment” which could create a hostile environment.
In settings where doula care was available, providers did not feel well trained on how to integrate them as active or important members of the support team. This may lead to providers feeling that doulas were “in the way”, evaluating the provider, or taking over the role of the provider.
We found that some doulas felt that they were not well integrated into decision-making or care coordination by healthcare providers, or were even ignored (low confidence). These doulas believed that healthcare providers assumed that doulas were working outside of or in conflict with the medical system, and were not considered to have valuable knowledge about labour or childbirth.
There may be some particular groups of women who can benefit from doula care provided by someone from their ethnic/religious/cultural community (community-based doula). For example, immigrant, refugee and foreign-born women resettled in high-income countries felt that community-based doulas helped them to receive culturally-appropriate care (low confidence).
Community-based doulas empowered women to ask questions, acted as the woman’s advocate, and ensured that their customs and traditions were respected. When women received this type of care, they felt more confident to give birth and less like ’outsiders’ in their new community.
From our research, we have a good understanding of women’s experiences of companionship, and their partners’ experiences of providing companionship. However, there was limited research evidence on healthcare providers’ experiences with lay companions and doulas, which is a key dimension of understanding the challenges and opportunities to providing this type of support. Future research could consider how healthcare providers of different cadres (midwives, nurses, medical officers, obstetricians) interact with companions and doulas, and how they may be better integrated into care.
We think that companionship may also have some important impacts on health equity, but more research is also needed to better understand this relationship. For example, if a refugee/migrant or Indigenous woman can be supported by someone from her cultural or ethnic background, she may have better experiences of care. For example, a qualitative study conducted with foreign-born women in Sweden found that support by community-based doulas helped them to overcome fear, maintain confidence, and feel less like an outsider (Akhavan 2012).
Where does this leave us?
As public health researchers, we are interested in exploring the best ways to make sure that all women who want a companion present during labour and childbirth have access to this type of support, from someone of her choice. This means that we want to empower women to make informed choices about their pregnancy and childbirth care, and ensure that care is provided to all women in a way that accounts for each women’s unique beliefs and fears.
Midwives are our key allies in this work, and play a critical role in helping to ensure that maternity services are designed to be woman-centred. We also want to make sure that where labour companionship is implemented, midwives and doctors have a role in designing services. This is critical to ensure that all healthcare providers are satisfied with their engagement, and that healthcare providers themselves feel empowered and respected.
Meghan Bohren has nothing to disclose.