In this blog for our Evidence for Everyday Health Choices series, Meghan Bohren (Lecturer in Gender and Women’s Health at University of Melbourne) and Sarah Chapman (Knowledge Broker at Cochrane UK) look at 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 supporting women throughout labour and childbirth and reflect on the role that support plays in women’s experiences of care.
News ahead of the arrival of Meghan and Harry’s baby that they were choosing to have the birth of the newest addition to the royal family at home, and without an early appearance for the cameras, was met in the press and on social media with complaints about this break with (only recent!) tradition and debate about the safety or otherwise of home birth. We also heard voices raised in support of a woman’s right to give birth in the place of her choosing, with privacy and with the company of a trusted supporter. Surely this would make for a better birth? Indeed we have evidence to support this assertion, and a new understanding of why this is so, as we explain here.
Women have traditionally been supported by a companion during childbirth, and there is good evidence that this has many benefits for both the woman and baby. Supporting women throughout labour and childbirth improves women’s experiences of care and health outcomes – isn’t this a no-brainer?
Unfortunately, not all women benefit from support, and may go through labour and birth alone in the hospital. I first noticed this while visiting labour wards in Nigeria back in 2013. I was struck that women were by themselves while in the early stages of labour, with no one there to rub their back through contractions or bring them a cup of tea. When the time came to push, a midwife was there between her legs, but no one was there to hold her hand and reassure her. This felt disconnected from my family and friends’ experiences of childbirth in the United States, where they were surrounded by their partner, and maybe a doula or their mum – all people who were present for the sole reason to provide her with comfort and love.
As a researcher focused on improving women’s experiences of maternity care, I sought to better understand how women are supported – and not supported – throughout labour and childbirth, especially in low- and middle-income countries.
Effect of continuous support on women’s and babies’ health
Two years ago, we explored what the effects are of women having continuous support during childbirth, by updating this Cochrane Review (Bohren et al, 2017) with the evidence from all the relevant research we could find: 26 studies 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, as continuously as practical in a given context. Continuous support was provided by a woman’s partner, family member, or friend; hospital staff (student midwives); or a doula.
Continuous support for women during childbirth is recommended by the World Health Organization (2018). Our Cochrane Review showed that continuous support may have several health benefits for both the woman and baby, and no harms have been identified.
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 to assess babies’ health and well-being at birth and shortly afterwards).
Learning from experiences of labour companionship
Now that we understood the positive effects of continuous support in labour and childbirth on women’s and babies’ health, we sought to understand how women, families and health workers experienced labour companionship. We were also interested in why this type of support wasn’t available for all women across the world. To answer these questions, we conducted a new Cochrane Review, looking for qualitative studies, which capture women’s, their family members’, healthcare providers’ and doulas’ perceptions and experiences of labour companionship (Bohren at al, 2019). We found 51 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.
Supporting women in four ways
We found that labour companions supported women in four different ways. Companions supported by giving information about childbirth, bridging communication gaps between health workers and women, and facilitating non-pharmacological pain relief. Companions were advocates, which means they spoke up in support of the woman. Companions provided practical support, including encouraging women to move around, providing massage, and holding her hand. Finally, companions gave emotional support, using praise and reassurance to help women feel in control and confident, and providing a continuous physical presence.
Understanding more about labour companions
Women who wanted a companion present during labour and childbirth needed this person to be compassionate and trustworthy. Companionship helped women to have a positive birth experience. Women without a companion could perceive this as a negative birth experience. Women had mixed perspectives about wanting to have a male partner present (we have low confidence in this finding). Generally, men who were labour companions felt that their presence made a positive impact on both themselves (low confidence) and on the relationship with their partner and baby (low confidence), although some felt anxious witnessing labour pain (low confidence). Some male partners felt that they were not well integrated into the care team or decision-making. Doulas often met with women before birth to build rapport and manage expectations. Women could develop close bonds with their doulas (low confidence). Foreign-born women in high-income settings may appreciate support from community-based doulas to receive culturally-competent care (low confidence). Where limitations in the evidence mean that we have low confidence in some of these findings, we hope that when we update the review there will be more studies conducted in different settings to include that strengthen the results.
What can get in the way of women having a companion?
Some women weren’t always able to have a companion during labour. This may be because health workers and women did not recognise the benefits of companionship, due to a lack of space and privacy, and fearing increased risk of infection (low confidence). Changing policies to allow companionship and addressing gaps between policy and practice were thought to be important (low confidence). Some providers were resistant to or not well trained on how to use companions, and this could lead to conflict. Lay companions were often not integrated into antenatal care, which may cause frustration (low confidence).
How does continuous support in labour help women and babies?
We have two main hypotheses about why continuous support is beneficial. First, in birthing environments that are stressful or potentially disempowering for a woman (think: a busy maternity ward with no private rooms, maybe no curtains between maternity beds), women may be more likely to experience institutional routines, high rates of intervention, unfamiliar healthcare providers, lack of privacy, and so on. These conditions may have a negative impact on her feelings of confidence and control. Continuous support in this situation may act as a buffer against these stressors. The second way that we think continuous support may work is more physiological. We know from research about fear and anxiety that anxiety during labour is associated with high levels of the stress hormone epinephrine in the blood, which may in turn lead to abnormal fetal heart rate patterns in labour, decreased uterine contractility, a longer active labour phase with regular well‐established contractions and low Apgar scores. Continuous support (including emotional support, information and advice, comfort measures and advocacy) may reduce anxiety and fear and associated adverse effects during labour.
And what’s all this about doulas?
You may have heard the term “doula” in the media recently, with rumours ahead of the birth of the royal baby that Meghan has hired a doula.
In some countries, doulas (pronounced doo-lah) are used to provide continuous support to women throughout pregnancy, childbirth and the postnatal period. The word “doula” comes from a Greek word meaning “woman’s servant”. 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.
Doulas typically meet with a woman (and sometimes her partner or family) during pregnancy to help her to prepare for childbirth, build rapport, manage expectations and provide evidence-based resources. When a woman goes into labour, she alerts her doula and they meet at the place she has chosen for the birth, where the doula supports the woman throughout labour and childbirth. This is typically at a birthing clinic or hospital (some doulas may attend home births).
While the cost of doula care may be prohibitive (think: £800-£2000 in the UK depending on the doula’s experience and offered services), our new evidence highlights that providing community-based doula care for migrant, refugee and other foreign-born women in high-income countries may be an important way for them to receive culturally-competent care and improve equity (Bohren et al, 2019). When migrant women receive care from community-based doulas, who are from the same ethnic, linguistic, and/or religious background, they may feel more confident and less like “outsiders” in their new communities. In Sweden (Akhavan and Edge, 2012) and the United States (LeMancuso et al, 2016), research has demonstrated that foreign-born women supported by a community-based doula were more satisfied with their birth experiences, and doulas themselves felt empowered.
Doula services may also be provided free-of-charge for low-income individuals and families, as a way to improve equity. The Doula Project and Birth for Humankind provide free doula services to low-income people in New York City and Melbourne.
Supporting women to have a labour companion or doula of her choice during childbirth is an effective way to improve health outcomes (Bohren et al, 2017) and is an important component of respectful maternity care (Shakibazadeh et al, 2018). Labour companionship and doula support may increase equity directly through improved women’s empowerment and provision of culturally-responsive care, and indirectly by reducing medicalization of childbirth (World Health Organization, 2018).
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. We want to involve women, their families, midwives, and doctors in co-designing maternity services that are more woman-centred. By woman-centred, we mean providing care in a way that accounts for and is respectful of each woman’s unique beliefs, desires, and fears. This is an important step in the direction of ensuring respectful and supportive maternity care for all women, everywhere. We also hope that by providing a description of the current evidence on labour companionship, women can use this information to make informed choices about their maternity care.
Meghan Bohren and Sarah Chapman have nothing to disclose.