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. 2017 Jul 6;7(7):CD003766.
doi: 10.1002/14651858.CD003766.pub6.

Continuous support for women during childbirth

Meghan A Bohren  1 , G Justus Hofmeyr, Carol Sakala, Rieko K Fukuzawa, Anna Cuthbert
Affiliations

Continuous support for women during childbirth

Meghan A Bohren et al. Cochrane Database Syst Rev. .

Abstract

Background: Historically, women have generally been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has often become the exception rather than the routine.

Objectives: The primary objective was to assess the effects, on women and their babies, of continuous, one-to-one intrapartum support compared with usual care, in any setting. Secondary objectives were 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, including: policies about the presence of support people of the woman's own choosing; epidural analgesia; and continuous electronic fetal monitoring.2. The provider's relationship to the woman and to the facility: staff member of the facility (and thus has additional loyalties or responsibilities); not a staff member and not part of the woman's social network (present solely for the purpose of providing continuous support, e.g. a doula); or a person chosen by the woman from family members and friends;3. Timing of onset (early or later in labour);4. Model of support (support provided only around the time of childbirth or extended to include support during the antenatal and postpartum periods);5. Country income level (high-income compared to low- and middle-income).

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (1 June 2017) and reference lists of retrieved studies.

Selection criteria: All published and unpublished randomised controlled trials, cluster-randomised trials comparing continuous support during labour with usual care. Quasi-randomised and cross-over designs were not eligible for inclusion.

Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We sought additional information from the trial authors. The quality of the evidence was assessed using the GRADE approach.

Main results: We included a total of 27 trials, and 26 trials involving 15,858 women provided usable outcome data for analysis. These trials were conducted in 17 different countries: 13 trials were conducted in high-income settings; 13 trials in middle-income settings; and no studies in low-income settings. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (average RR 1.08, 95% confidence interval (CI) 1.04 to 1.12; 21 trials, 14,369 women; low-quality evidence) and less likely to report negative ratings of or feelings about their childbirth experience (average RR 0.69, 95% CI 0.59 to 0.79; 11 trials, 11,133 women; low-quality evidence) and to use any intrapartum analgesia (average RR 0.90, 95% CI 0.84 to 0.96; 15 trials, 12,433 women). In addition, their labours were shorter (MD -0.69 hours, 95% CI -1.04 to -0.34; 13 trials, 5429 women; low-quality evidence), they were less likely to have a caesarean birth (average RR 0.75, 95% CI 0.64 to 0.88; 24 trials, 15,347 women; low-quality evidence) or instrumental vaginal birth (RR 0.90, 95% CI 0.85 to 0.96; 19 trials, 14,118 women), regional analgesia (average RR 0.93, 95% CI 0.88 to 0.99; 9 trials, 11,444 women), or a baby with a low five-minute Apgar score (RR 0.62, 95% CI 0.46 to 0.85; 14 trials, 12,615 women). Data from two trials for postpartum depression were not combined due to differences in women, hospitals and care providers included; both trials found fewer women developed depressive symptomatology if they had been supported in birth, although this may have been a chance result in one of the studies (low-quality evidence). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, such as admission to special care nursery (average RR 0.97, 95% CI 0.76 to 1.25; 7 trials, 8897 women; low-quality evidence), and exclusive or any breastfeeding at any time point (average RR 1.05, 95% CI 0.96 to 1.16; 4 trials, 5584 women; low-quality evidence).Subgroup analyses suggested that continuous support was most effective at reducing caesarean birth, when the provider was present in a doula role, and in settings in which epidural analgesia was not routinely available. Continuous labour support in settings where women were not permitted to have companions of their choosing with them in labour, was associated with greater likelihood of spontaneous vaginal birth and lower likelihood of a caesarean birth. Subgroup analysis of trials conducted in high-income compared with trials in middle-income countries suggests that continuous labour support offers similar benefits to women and babies for most outcomes, with the exception of caesarean birth, where studies from middle-income countries showed a larger reduction in caesarean birth. No conclusions could be drawn about low-income settings, electronic fetal monitoring, the timing of onset of continuous support or model of support.Risk of bias varied in included studies: no study clearly blinded women and personnel; only one study sufficiently blinded outcome assessors. All other domains were of varying degrees of risk of bias. The quality of evidence was downgraded for lack of blinding in studies and other limitations in study designs, inconsistency, or imprecision of effect estimates.

Authors' conclusions: Continuous support during labour may improve outcomes for women and infants, including increased spontaneous vaginal birth, shorter duration of labour, and decreased caesarean birth, instrumental vaginal birth, use of any analgesia, use of regional analgesia, low five-minute Apgar score and negative feelings about childbirth experiences. We found no evidence of harms of continuous labour support. Subgroup analyses should be interpreted with caution, and considered as exploratory and hypothesis-generating, but evidence suggests continuous support with certain provider characteristics, in settings where epidural analgesia was not routinely available, in settings where women were not permitted to have companions of their choosing in labour, and in middle-income country settings, may have a favourable impact on outcomes such as caesarean birth. Future research on continuous support during labour could focus on longer-term outcomes (breastfeeding, mother-infant interactions, postpartum depression, self-esteem, difficulty mothering) and include more woman-centred outcomes in low-income settings.

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Conflict of interest statement

Meghan Bohren: is conducting a related Cochrane qualitative evidence synthesis on labour companionship (Bohren 2016).

Justus Hofmeyr: is an author of one study included in this review and did not participate in decisions, assessment or data extraction related to this study (Hofmeyr 1991).

Carol Sakala: none known.

Rieko Fukuzawa: I am a nurse‐midwife by background. I have received lecture fees provided by Child Research Net (http://www.childresearch.net/overview.html), a web‐based non‐profit research institution in Tokyo. I have also been a guest researcher for Child Research Net since 2005 and have received 15000 yen (about $130) per article as an author, but other than that, no salary. As part of the Child Research Net, I run a ‘Doula Laboratory’(http://www.blog.crn.or.jp/lab/03/). I was a volunteer advisor for the Ippan Shadan Houjin Doula Kyoukai (incorporated association: https://www.doulajapan.com/) from April 2012 to July 2015. Currently I am conducting a government‐funded study on the development and evaluation of a non‐medical support program for women during childbirth in Japan (total 4,810,000 yen (about US$42,000) from April 2016 through March 2019. I received a grant from University of Tsukuba to cover the professional translation fee for Japanese translation of this review in February 2017 (268,964 yen (about US$2,400)).

Anna Cuthbert: none known.

Figures

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Study flow diagram
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Methodological quality summary: review authors' judgements about each methodological quality item for each included study
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Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies
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Funnel plot of comparison: 1 Continuous support versus usual care ‐ all trials, outcome: 1.1 Spontaneous vaginal birth
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Funnel plot of comparison: 1 Continuous support versus usual care ‐ all trials, outcome: 1.2 Negative rating of/negative feelings about birth experience
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Funnel plot of comparison: 1 Continuous support versus usual care ‐ all trials, outcome: 1.9 Labour length
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Funnel plot of comparison: 1 Continuous support versus usual care ‐ all trials, outcome: 1.6 Any analgesia/anaesthesia
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Funnel plot of comparison: 1 Continuous support versus usual care ‐ all trials, outcome: 1.12 Instrumental vaginal birth
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Funnel plot of comparison: 1 Continuous support versus usual care ‐ all trials, outcome: 1.11 Caesarean birth
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Funnel plot of comparison: 1 Continuous support versus usual care ‐ all trials, outcome: 1.18 Low 5‐minute Apgar score
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Funnel plot of comparison: 1 Continuous support versus usual care ‐ all trials, outcome: 1.8 Synthetic oxytocin during labour
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References

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Trueba 2000 {published and unpublished data}
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Wan 2011 {published data only (unpublished sought but not used)}
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Zhang 1996b {published data only}
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References to studies awaiting assessment

Aghdam 2015 {published data only}
    1. Aghdam SK, Kazemzadeh F, Nikjoo R. The effect of the doula support during labor on delivery length in primigravida women. Iranian Journal of Obstetrics, Gynecology and Infertility 2015;18(150):8‐13.
Bakhshi 2015 {published data only}
    1. Bakhshi M, Kordi M, Esmaeeli H. The effect of continuous support during labor on the onset of lactogenesis stage II in primiparas. Journal of Mazandaran University of Medical Sciences 2015;25(130):153‐8.
Farahani 2005 {published data only}
    1. Farahani SHM, Malekzadegan A, Mohammadi R, Hosseini F. Effect of the one to one midwifery care during labor on modes of delivery. Iran Journal of Nursing 2005;18(43):71‐82.
Huang 2003 {published data only}
    1. Huang XH, Xiang XY, Shen RG, Shang Q, Zhu LP, Qian X, et al. Study on intrapartum service model during normal labor. Chung‐Hua Fu Chan Ko Tsa Chih [Chinese Journal of Obstetrics and Gynecology] 2003;38(7):385‐7. - PubMed
IRCT2013111710297N3 {published data only}
    1. IRCT2013111710297N3. Effect of the presence of support person and routine intervention for women during childbirth in Isfahan, Iran: A randomized controlled trial. en.search.irct.ir/view/15847 (first received 25 November 2013). - PMC - PubMed
McGrath 1999 {published data only}
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NCT00664118 {published data only}
    1. NCT00664118. Doula combined latent phrase epidural analgesia in primiparous women (DCLEAP). clinicaltrials.gov/ct2/show/NCT00664118 (first received 18 April 2008).
Pinheiro 1996 {published data only}
    1. Pinheiro RT, Sousa PLR, Horta B, Souza RM, Sousa MGR, Sousa FR. Male and female young doulas ‐ effective on labour? [abstract]. Xth World Congress of Psychiatry; 1996 August 23‐28; Madrid, Spain. 1996.
Rahimiyan 2015 {published data only}
    1. Rahimiyan MN, Rahnavard T, Lari MZ. Effect of the one to one midwifery care during labor on modes of delivery and duration of labor and increase satisfaction with childbirth. Biosciences Biotechnology Research Asia 2015; Vol. 12.
Samieizadeh 2011 {published data only}
    1. Samieizadeh T, Sereshti M, Dashipur A R, Mohammadinia N, Arzani A. The effect of supportive companionship on length of labor and desire to breastfeed in primiparous women. Journal of Urmia Nursing and Midwifery Faculty 2011;9(4):1‐9.
Sangestani 2013 {published data only}
    1. IRCT201112106827N2. The influence of doula on the parturient anxiety in delivery ward, 2011. en.search.irct.ir/view/8079 (first received 17 January 2012).
    1. Sangestani G, Khatiban M, Pourolajal J, Oshvandi K. Influence of doula on the primiparous parturients' anxiety in the delivery ward. Hayat 2013;19(4):48‐60.
Shahshahan 2014 {published data only}
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References to ongoing studies

IRCT2015083123837N1 {published data only}
    1. IRCT2015083123837N1. Studying the impacts of the combination of effective methods compared with doula on reducing anxiety and pain of mothers in childbirth in the Jam Tohid Hospital in 2015. en.search.irct.ir/view/25405 (first received 26 October 2015).
NCT01216098 {published data only}
    1. NCT01216098. Impact of doula support on intrapartum outcomes for women undergoing a vaginal birth after cesarean (vbac). clinicaltrials.gov/ct2/show/NCT01216098 (first received 5 October 2010).
NCT01947244 {published data only}
    1. NCT01947244. Illinois maternal, infant, and early childhood home visiting (miechv): doula randomized controlled trial. clinicaltrials.gov/show/NCT01947244 (first received 13 September 2013).
NCT02550730 {published data only}
    1. NCT02550730. Birth sisters best beginnings evaluation. clinicaltrials.gov/ct2/show/record/NCT02550730 (first received 23 June 2015).

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References to other published versions of this review

Hodnett 2003
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Hodnett 2011
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Hodnett 2012
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