Supporting Women in Labor: Analysis of Different Types of Caregivers

Patricia Rosen, CNM, MSN

Disclosures

J Midwifery Womens Health. 2004;49(1) 

In This Article

Abstract and Introduction

Abstract

Continuous labor support offers multiple benefits for mothers and infants. The type of caregiver that is the best support person in labor has not been identified. A critical review of the English language literature was conducted to describe the current state of knowledge on different types of labor support persons. Randomized trials and other published reports were identified from relevant databases and hand searches. Studies were reviewed and assessed by using a structured format. Eight randomized trials met the selection criteria for inclusion in this analysis. These trials investigated untrained and trained lay women, female relatives, nurses, lay midwives, and student lay midwives as labor support persons. Support by untrained lay women starting in early labor and continuing into the postpartum period demonstrates the most consistent beneficial effect on childbirth outcomes. However, more randomized controlled trials are warranted before firm conclusions may be drawn.

Introduction

In the last century, birth in the United States (US) moved from a woman-supported experience in the home to a highly medicalized event in the hospital.[1] Although immediate pregnancy outcomes for mother and baby have improved, rates of medical intervention and operative delivery have increased, and problems such as failure to breastfeed, difficulties coping as a mother, and high rates of postpartum depression remain prevalent.[2] Research suggests that continuous labor support may mitigate some of these adverse outcomes.

To assess who might best provide labor support, one must first understand exactly what labor support is and how it works. The primary theorized mechanism of action involves the cycle of fear-tension-pain observed by Dr. Grantley Dick-Read, an early proponent of childbirth education and labor support.[3] The theory states that pain and anxiety during labor lead to an endogenous release of catecholamines, which lower uterine contractility and decrease placental blood flow. Less anxiety means decreased catecholamines, improved uterine contractility and efficiency, and a reduced risk of prolonged labor or fetal distress.[3,4] Women with continuous labor support feel empowered and in control and, therefore, experience less anxiety than their non-supported counterparts.[3,5]

The components of labor support that women report finding helpful are emotional support (continuous presence, reassurance, encouragement, and praise); physical support (comfort measures aimed at decreasing hunger, thirst, or pain); information and advice about what is happening and how to cope; advocacy (respecting her decisions and helping to communicate those to the health care team); and caregiver support of the partner/husband.[6] All of these components imply a human presence that accepts a woman's behaviors, attitudes, and individual preferences.[6]

Systematic review of the literature demonstrates that support in active labor by an experienced female companion is associated with significantly less need for analgesia, forceps or vacuum extraction, and cesarean births, fewer low Apgar scores,[7,8] shorter duration of labor, decreased oxytocin augmentation,[1] and an increased sense of personal control.[9] In the long term, support is associated with lower rates of postpartum depression, failed breastfeeding, difficult mothering, and negative perceptions of the birth experience.[8] According to a 1999 metanalysis,[10] positive outcomes are limited to studies in which continuous labor support is compared with none at all; in trials that include intermittent labor support, no significant differences are seen.[10] To date, no critical review has analyzed the effectiveness of labor support by different types of support persons. The purpose of this article is to review the evidence regarding the types of caregivers who can offer effective support in labor.

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