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MumsnetGuestPosts (MNHQ) Fri 22-Mar-19 14:22:41

Guest Post: “Continuous support during labour may improve health outcomes for both the woman and baby”

Meghan Bohren (Lecturer and researcher in Gender and Women’s Health) and Sarah Chapman (Knowledge Broker) explain new research evidence on supporting women during labour and childbirth.

Meghan Bohren

Lecturer and researcher in Gender and Women’s Health

Posted on: Fri 22-Mar-19 14:22:40

(22 comments )

Lead photo

"Supporting all women to have a labour companion of her choice during childbirth is an effective way to improve health outcomes"

With Prince Harry and Meghan Markle’s baby due very soon, speculation is mounting about their choices for the birth, including talk of Meghan hiring a doula. If she has, when she goes into labour, someone who knows her birth plan and has built up a rapport with her during pregnancy will arrive at her chosen place for the birth to support her through labour and childbirth - quicker than you can say “Brexit baby”. This, in a nutshell, is the role of doulas, who are trained non-medical professionals.

Women have traditionally been supported by a companion of their choice during childbirth, and this has many benefits for both the woman and baby. We know this from the best available research evidence on the effects of continuous support in labour, brought together in a Cochrane Review.

Now there is new evidence providing insights into the ways in which women are supported during childbirth, that could help ensure that more women benefit.

Research involving over 15,000 women has shown that continuous support during labour may improve health outcomes for both the woman and baby, whether it is provided by a woman’s partner, family member, or friend; hospital staff (student midwives) or a doula, and no risks have been identified. Women who receive continuous support may be more likely to give birth ‘spontaneously’, (ie vaginally with neither caesarean nor forceps nor vacuum extraction), have shorter labours and be satisfied with their birth experience. What’s more, they may be less likely to use pain medications, and their babies may be less likely to have low five-minute Apgar scores (the score used to assess babies’ health and wellbeing at birth and shortly afterwards).

Labour companionship and doula support may increase equity - directly through improved women's empowerment and culturally-responsive care, and indirectly by reducing medicalization of childbirth.


Our new research has shown that labour companions (including doulas, partners, and family members), support women in four key ways. Firstly, through providing information, they bridge communication gaps between health workers and the woman, keep her informed about the process of childbirth and facilitate use of non-pharmacological pain relief (such as meditation). Labour companions advocate for the woman, speaking up in support of her and her preferences. They also give practical support, including encouraging the woman to move around, providing massage, and holding her hand. Finally, companions give emotional support, helping the woman to feel in control and confident by praising and reassuring, and providing a continuous physical presence.

So having a trusted companion through labour and childbirth is a Good Thing and it doesn’t have to be a doula. But if you think doulas are just for royalty and the rich, think again. Hiring their services can be expensive; in the UK, doula services range from £800-£2000 depending on the doula’s experience and offered services. But doula services may be provided free-of-charge for low-income individuals and families. The Doula Access Fund Charity is being established to provide doula care to those in financial, practical or emotional hardship, who would otherwise be alone through pregnancy and childbirth.

Something the research highlights is 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. 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 and the United States, 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.

So 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. Supporting all women to have a labour companion of her choice during childbirth is an effective way to improve health outcomes, and is an important component of respectful maternity care.

Whatever Meghan’s birth choices turn out to be, we hope she will be supported by someone she trusts throughout her labour and childbirth, and that’s something every woman and baby should be able to benefit from.

For more information about doula services and hiring a doula: Doula UK

Meghan Bohren will be returning to the post on 25th March at 9am to answer your questions.

By Meghan Bohren

Twitter: @DoulaUK

JohnnyMcGrathSaysFuckOff Fri 22-Mar-19 20:49:33

Tbh, I'd be happier if antenatal and obstetric HCP started with a) acknowledging that women are people with choices and LISTENED to us and b) stopped ramming their ideas about what makes a good birth down women's throats, whether those ideas be super medicalised birth or labouring on one's own at home.

OhTheRoses Fri 22-Mar-19 22:17:42

Is this because hcps have lost all compassion or because it's yet another way of the nhs avoiding what it's paid to do?

NewAccount270219 Fri 22-Mar-19 22:25:47

Research involving over 15,000 women has shown that continuous support during labour may improve health outcomes for both the woman and baby, whether it is provided by a woman’s partner, family member, or friend; hospital staff (student midwives) or a doula

I'm a bit confused by this - given the wide group of people who you count as supports, aren't the only women who don't have this women who spend their labour entirely alone? Is that common?

canihaveacoffeeplease Sat 23-Mar-19 04:44:42

I had 2 home births (not everyone's choice and I'm not trying to start an argument about them) and I was lucky enough at both births to have my community midwife in attendance who was fantastic. She had done most of my antenatal appointments, been to my home, met my husband, and I felt we built up a good rapport. It was luck that 'my' midwife was on call both times the night I went into labour, but I had met most of the midwives in the homebirth team, which still would've helped having someone i knew attend, even if not knowing them so well.

As someone with a pretty big fear of hospitals/medics/birth interventions, and someone very very private, I truly credit this with a good outcome at both births. I had someone in attendance the whole way through who I knew and trusted 100%, and when things got tough she really helped me through and did what was needed. She was also there when I needed her, and knew when to leave me alone, which was brilliant. My first birth was long and tiring and not easy, but I had 100% faith in her and it all ended well. She also stayed 4 hours beyond the end of her shift and cancelled the midwife who was supposed to come after her so she could be there for me-truly amazing (there was a second midwife there too). She also did most of my checks in the 2 weeks following the birth, which was lovely.

I think it must be really hard to go through something so personal and private with people you've just met, I would really struggle to build up a rapport with someone so quickly.

I am aware I was extremely lucky to have such amazing continuity of care without being a private patient, however I strongly feel this should be the norm for pregnant women. One to one midwives (although not in my area) provide an excellent example of how this can be achieved, and I do feel it is so important to provide women with this feeling of security and that things need to change to accommodate this.

axil Sat 23-Mar-19 06:35:06

Three questions:

1. Would you say that the continuous support boils down to reducing fear in the labouring woman, both psychologically and physically?

2. I'm wondering how the research defined continuous support. A partner present isn't unusual but there's a difference between the sort of support a doula or one-to-one midwife gives, someone who's studied and been at many labours and a partner who is watching their other half labour for the first time (particularly), or second. Being present isn't the same as continuous support.

3. The 15,000 births, were they first births or subsequent ones? Did the data make that split? If so what was the difference both between first and subsequent births with continuous support and between outcomes of each compared to their respective general population?

BigFatGiant Sat 23-Mar-19 12:11:08

Would be a bit unnecessary if labouring women weren’t ignored for hours at a time by hospital staff.

Preggosaurus9 Sat 23-Mar-19 13:44:37

A bit mystifying. Isn't it common sense that a woman with someone she trusts supporting her, is going to have a better experience than a woman left alone and only intermittently interacted with by medical staff? Same for the outcomes for baby, is it not common sense that a supportive person being present would help those too?

Bit weird, having to collect "evidence" of common bloody sense.

NewAccount270219 Sat 23-Mar-19 13:55:52

I also wonder when this supportive care is supposed to start, because I and every other mum I know in my local area had the experience of being told not to come to hospital until the staff very reluctantly felt it was completely necessary - in my case they insisted I wasn't in active labour and no one even examined me until I repeatedly demanded it because I needed to push, at which point they discovered that I was indeed past transition and pushing. Mine was the worst but we all (from my antenatal group) got put off later than we wanted, I think because they are so genuinely short of resources (they had a mad panic to find me a room when they realised I was actually about to give birth). If I'd been assigned a student midwife as 'continuous support' at that point it would have been a bit of a joke!

NopeNi Sat 23-Mar-19 15:04:49

I mean, great, but shouldn't this be filed under "no shit Sherlock"?

It seems awful to me that you have to be wealthy enough to pay for private support to have a good labour.

The NHS should have better funding for pregnancy support, it affects literally everyone who's born in the country.

PanamaPattie Sat 23-Mar-19 21:54:16

In other news, water is wet.

Shiroc Sat 23-Mar-19 22:23:30

I have invited a 5 years old girl to come over for play date a few times. Her behaviour is quite terrible. She shouts and she don't listen. For example she takes slimes on the carpet despite asking her not to do so, she demands things and if she don't get them she screams. I am contemplating not to invite her again. What are your thoughts?

3boysandabump Sun 24-Mar-19 14:16:45

But what about those of us who can't afford a doula?

FuzzyShadowChatter Sun 24-Mar-19 19:41:11

As much as I support common sense research as it can be hard to get funding for common sense initiatives or further research without it, I think the way this is being written about and shown may be unhelpful. While it lists four 'roles', the continuous support still comes across as just being there rather than people fulfilling those important roles for women in labour.

I have four kids, first and last were hospital births and the two middle kids were home births, and the quality of the people and the support they gave was a large part of the deciding factor of how I felt about the birth and how well I managed during and afterward, far more than location or the complications that happened or even the amount they were there. While continuous support is of great benefit, I think care needs to be taken that it's done and promoted as continuous quality support and that healthcare professionals, family, and those hired like doulas have ways to learn and are supported in the on-going research in this area.

MeghanBohren Mon 25-Mar-19 09:00:44

Hello everyone! Meghan Bohren here, thank you so much for all of your questions and I look forward to answering them. I am a Lecturer in Gender and Women’s Health, and my research focuses on improving maternal health, especially women’s experiences of pregnancy and childbirth care.

MeghanBohren Mon 25-Mar-19 09:02:43

NewAccount270219

*Research involving over 15,000 women has shown that continuous support during labour may improve health outcomes for both the woman and baby, whether it is provided by a woman’s partner, family member, or friend; hospital staff (student midwives) or a doula*

I'm a bit confused by this - given the wide group of people who you count as supports, aren't the only women who don't have this women who spend their labour entirely alone? Is that common?

Hello @NewAccount270219, great question. In the Cochrane review where this evidence comes from (see link below), the randomised controlled trials were conducted in 17 different countries (including the UK). Maternity care services are organised quite differently in these settings. In some countries and hospitals, women are not allowed to have anyone with them during childbirth except for the health staff. This means that their husbands/partners/friends/family all have to wait outside of the room and generally do not have contact with her until after the baby is born. In these cases, women are alone, except for when interacting with a midwife or nurse or doctor. In other settings (like the UK), women are allowed to have their husbands/partners/friends/family. In the randomised controlled trials conducted in these settings, the researchers explored the effect of an additional person providing support, who was typically a doula, or a healthcare provider providing continuous support.
www.cochrane.org/CD003766/PREG_continuous-support-women-during-childbirth

MeghanBohren Mon 25-Mar-19 09:11:08

canihaveacoffeeplease

I had 2 home births (not everyone's choice and I'm not trying to start an argument about them) and I was lucky enough at both births to have my community midwife in attendance who was fantastic. She had done most of my antenatal appointments, been to my home, met my husband, and I felt we built up a good rapport. It was luck that 'my' midwife was on call both times the night I went into labour, but I had met most of the midwives in the homebirth team, which still would've helped having someone i knew attend, even if not knowing them so well.

As someone with a pretty big fear of hospitals/medics/birth interventions, and someone very very private, I truly credit this with a good outcome at both births. I had someone in attendance the whole way through who I knew and trusted 100%, and when things got tough she really helped me through and did what was needed. She was also there when I needed her, and knew when to leave me alone, which was brilliant. My first birth was long and tiring and not easy, but I had 100% faith in her and it all ended well. She also stayed 4 hours beyond the end of her shift and cancelled the midwife who was supposed to come after her so she could be there for me-truly amazing (there was a second midwife there too). She also did most of my checks in the 2 weeks following the birth, which was lovely.

I think it must be really hard to go through something so personal and private with people you've just met, I would really struggle to build up a rapport with someone so quickly.

I am aware I was extremely lucky to have such amazing continuity of care without being a private patient, however I strongly feel this should be the norm for pregnant women. One to one midwives (although not in my area) provide an excellent example of how this can be achieved, and I do feel it is so important to provide women with this feeling of security and that things need to change to accommodate this.

@canihaveacoffeeplease, that sounds like you had a great experience, and were able to make informed decisions about you and your baby’s health, while supported by a wonderful team! This is fantastic, thank you so much for sharing your story. I agree that continuity of care with the same provider or team of providers is beneficial to helping women feel comfortable. There is some great evidence from Cochrane about the benefits of midwife-led continuity of care (see link below). Researchers found that women who had midwife-led continuity of care were less likely to have epidural, had fewer episiotomies and instrumental births. They were also more likely to have spontaneous vaginal births (births that are not introduced).
www.cochrane.org/CD004667/PREG_midwife-led-continuity-models-care-compared-other-models-care-women-during-pregnancy-birth-and-early

MeghanBohren Mon 25-Mar-19 09:24:31

axil

Three questions:

1. Would you say that the continuous support boils down to reducing fear in the labouring woman, both psychologically and physically?

2. I'm wondering how the research defined continuous support. A partner present isn't unusual but there's a difference between the sort of support a doula or one-to-one midwife gives, someone who's studied and been at many labours and a partner who is watching their other half labour for the first time (particularly), or second. Being present isn't the same as continuous support.

3. The 15,000 births, were they first births or subsequent ones? Did the data make that split? If so what was the difference both between first and subsequent births with continuous support and between outcomes of each compared to their respective general population?

@azil, great questions! In response to your first question, yes, reducing fear for the woman in labour is definitely one component of why we think there are positive benefits of continuous support. 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.

In response to your second question, 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. Studies conducted in this area have varied in their definitions of “continuous”, for example this includes “with no interruption”, “minimum of 80% of the time”, and “as continuously as possible”.

In response to your third question, this was a mix of first births and subsequent births. Our research was a Cochrane review, which means that we synthesized the results of all randomised controlled trials on this topic. Not all of the randomised separated their data by first birth and subsequent births, so we were not able to separate our results based on this.

MeghanBohren Mon 25-Mar-19 09:35:37

Several of you have posted questions about this being “common sense research”. I agree, and I really wish that all women, everywhere in the world, had the type of support that they want during pregnancy and childbirth – whether it is provided by a partner, family member, friend, doula, midwife, or doctor! Unfortunately, we also know that many women don’t have access to this type of support (which we call labour companions. One of the key things that our research explores are reasons why women don’t always have access to labour companions. Some of the key reasons we identified include that both health workers and women may not realise the benefits of laour companions, and that not all health facilities have policies allowing women to bring labour companions with them. We also noted that in very crowded maternity wards, there may be challenges around maintaining privacy and confidentiality for women giving birth, when there are also labour companions present (think: one woman’s boyfriend being able to see another woman giving birth!) This means that we also need to make sure that health facilities are structured in a way that maintain privacy for women. Lastly, we also found that not all healthcare providers are trained on how to include labour companions in the process of care. This may make everyone present frustrated or discouraged. To address this, it is probably most useful to include the labour companion during antenatal care visits or childbirth education classes, and also to make sure that providers understand how labour companions can help out.

MeghanBohren Mon 25-Mar-19 09:39:10

3boysandabump

But what about those of us who can't afford a doula?

@3boysandabump The Doula Access Fund is being created to provide doula services free of charge to women in the UK – this is such exciting news, and you can read more about what’s happening here: doula.org.uk/doula-%20access-fund/

MeghanBohren Mon 25-Mar-19 09:45:48

FuzzyShadowChatter

As much as I support common sense research as it can be hard to get funding for common sense initiatives or further research without it, I think the way this is being written about and shown may be unhelpful. While it lists four 'roles', the continuous support still comes across as just being there rather than people fulfilling those important roles for women in labour.

I have four kids, first and last were hospital births and the two middle kids were home births, and the quality of the people and the support they gave was a large part of the deciding factor of how I felt about the birth and how well I managed during and afterward, far more than location or the complications that happened or even the amount they were there. While continuous support is of great benefit, I think care needs to be taken that it's done and promoted as continuous quality support and that healthcare professionals, family, and those hired like doulas have ways to learn and are supported in the on-going research in this area.

@FuzzyShadowChatter I love your comment! I agree with you 100%, continuous support absolutely needs to be of high quality. It’s so much more than just “being there”. We are exploring how we can use participatory methods in our research in this area to ensure that all people have a voice, including women, doulas, healthcare providers, family members, and so on. Hearing peoples’ stories about their experiences giving birth and/or providing support can help us to better understand how we can design services that take these diverse experiences into account.

MeghanBohren Mon 25-Mar-19 10:18:43

Thanks everyone, I'm signing off for now. Have a lovely week!

agnurse Mon 25-Mar-19 17:55:18

I think a strong rationale for having a doula is that a doula is dedicated solely to providing emotional support to the mother.

Not everyone is fortunate enough to have family support around them. You have women who live far from their families (or don't have families), women who don't have a partner, or women whose partners are unable to be with them (due to distance, disinterest, or simply not being good at handling these types of situations).

I'm a nurse and have worked in L&D. Sometimes it is not physically possible to have one nurse dedicated solely to a patient in labour, depending on how far the labour has progressed. Not to mention that the nurse has other duties to perform, as well, such as monitoring the baby's heart rate, getting the room set up for the birth, and monitoring the mother's vital signs. Now, all of that can definitely be coordinated (as best as possible) around the mother's needs, but some women find that having a support person whose sole job is to be there for them on an emotional level is very helpful.

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