BIRTH 19:l March 1992
38
In the Literature Commentary on: Continuous emotional support during labor in a US hospital. A randomized controlled trial. Kennell J, Klaus M, McGrath S, Robertson S, Hinkley C: JAMA 1991;265:2197-2201.
Labor Support: Many Unanswered Questions Remain These authors provide additional evidence that emotional support during labor has a beneficial effect on the outcome of birth. This phenomenon was recognized more than 40 years ago by Grantly DickRead in his classic monograph, Childbirth Without Fear. One of the most gratifying features of a normal labor is the personal interest and undivided attention given by the attendant of the parturient woman. This applies particularly to primiparae. However great the confidence and courage, the knowledge that someone competent to understand is nearby affords a comforting sense of security. (1)
In the latter half of the twentieth century the hospital has replaced the home as the birthing place, a transition that occurred out of concern for the occasional catastrophic complications of pregnancy and delivery. When this happened, however, the emotional support provided by women of the family and community and by midwife attendants that was characteristic of home births was often left behind. In addition, today in the hospital the laboring woman is often subjected to technologic and operative interventions, and birth attendants are nurses, nurse-midwives, and physicians whose focus is often on collecting and interpreting data rather than caring for the emotional needs of the woman in labor. The importance of the birth attendant was identified in one of the first randomized, controlled trials comparing continuous electronic fetal heart rate monitoring to intermittent fetal heart rate auscultation (2,3). Although perinatal outcome showed no difference in the various monitoring groups, women who underwent monitoring had a lower cesarean delivery rate, and fewer showed continuous fetal heart rate tracings characteristic of uteroplacental
insufficiency. The authors suggested that the decreased frequency of “fetal distress” associated with monitoring may have been related to the presence of a nurse at the woman’s bedside throughout her labor. The “active management of labor,” as described and practiced at the National Maternity Hospital in Dublin, is characterized by a high frequency of oxytocin augmentation of labor, a remarkably low cesarean delivery rate, minimal use of analgesia and epidural anesthesia, and perinatal outcomes comparable to those in hospitals with a less aggressive approach (4). Although it is difficult to know precisely which of the ingredients of this protocol is responsible for its success, the authors give much of the credit to the midwives who are in constant attendance with the women. The findings of Kennell et a1 in this United States study and their previous studies in Central America (5,6) strongly suggest that the emotional support of a nonfamily member reduces labor complications and the associated obstetric and surgical interventions. A recent randomized, controlled trial in a low-income population reported that supportive companionship provided by nonhealth care community volunteers decreased perceived pain and anxiety during labor and increased successful breastfeeding, although it did not influence the duration of labor (7). The preceding studies demonstrating the beneficial effects of a birth attendant (doula) were conducted in low socioeconomic populations. It is not clear that the same benefits would be found in women of high socioeconomic status. Hodnett and Osborn performed a randomized, prospective trial to assess the effect of a birth attendant on low-risk, middle-class women in Toronto (8,9). Although
BIRTH 19:l March 1992
women accompanied by a birth attendant used less pain medication and had fewer episiotomies, the study did not demonstrate an effect on length of labor, cesarean delivery rate, or use of interventions such as forceps and oxytocin augmentation of labor. Many questions remain unanswered about the effect of social and emotional support for women in labor. A thorough review of the existing trials and research emphasizes the paucity of good research on the subject (10). Further data are needed about the effect of birth attendants on populations of different socioeconomic status and cultural background. It is also important to assess whether obstetric nurses or midwives, on a one-to-one basis, can provide emotional support during labor equivalent to that of a birth attendant. If it becomes clear that women with designated birth attendants have better liibor and birth outcomes, we have to determine the criteria for selecting these attendants. Must they be nonfamily? Must they be women? Must they have had a normal birth experience? Will they add to the ever-increasing costs of maternity care? For seven years in the 1960s as a medical student, resident, and consultant at two homes for unwed mothers in Denver, I experienced at firsthand the importance of emotional and social support in pregnancy and childbirth. Both homes had freestanding birth centers, with obstetric coverage and consultiition provided by the University of Colorado Medical Center. I recall vividly that labors were seldom prolonged, women required little analgesia, the cesarean delivery rate was remarkably low, and the perinatal mortality was as low as anywhere else in the state. One might have expected otherwise, since patients were mostly young primigravidas whose lives were in turmoil. In addition to their support from other residents and social workers during the late weeks of pregnancy, they were attended in labor by middle-aged nurses who knew each woman personally and provided the continuity and emotional support that are characteristic of the modern monitrice or birthing assistant. Whatever else the studies on emotional support in labor have demonstrated, none has shown any adverse effects and most have shown an improvement in patient self-esteem and personal satisfac-
39 tion. For this reason alone, every maternity service should ensure the presence of a caring individual who has the time and motivation to be with women throughout labor. The challenge for modern obstetric care is to combine the benefits of properly applied technology with those that the presence of a birth attendant provides. Furthermore, and perhaps most difficult, this must be achieved in a way that does not incessantly escalate the cost out of proportion to the benefits. This study by Kennell et a1 demonstrates clearly the benefits to be gained from such practice. Its importance cannot be overemphasized. Watson A. Bowes Jr., M.D. Department of Obstetrics and Gynecology University of North Carolina Chapel Hill, NC References I . Dick-Read G. Childbirth Without Fear. New York: Harper & Brothers, 1944:150. 2. Haverkamp AD, Thompson HE, McFee JG, Cetrulo C. The evaluation of continuous fetal heart rate monitoring in high-risk pregnancy. Am J Obstet Gynecol 1976;125:310320. 3. Haverkamp AD, Orleans M, Langendoerfer S, et al. A controlled trial of the differential effects of intrapartum fetal monitoring. Am J Obstef Gynecol 1979;134:399408. 4. Boylan PC. Active management of labor: Results in Dublin, Houston, London, New Brunswick, Singapore, and Valparaiso. Birth 1989;16(3):114-118. 5 . Sosa R, Kennell J, Klaus M, et al. The effects of a supportive companion on perinatal problems, length of labor, and mother-infant interaction. N Engl J Med 1980;303:597-600. 6. Klaus M, Kennell J, Robertson S, Sosa R. Effects of social support during parturition on maternal-infant morbidity. Br Med J 1986;293:585-587. 7. Hofmeyr GJ, Nikodem VC, Wolman W, et al. Companionship to modify the clinical birth environment: Effects on progress and perceptions of labour, and breastfeeding. Br J Obstet Gynaecol 1991;98:75&764. 8. Hodnett ED, Osborn RW. Effects of continuous intrapartum professional support on childbirth outcomes. Res Nurs Health 1989;12:289-297. 9. Hodnett ED, Osborn RW. A randomized trial of the effects of monitrice support during labor: Mothers’ views two to four weeks postpartum. Birth 1989;16(4):177-183. 10. Keirse MJNC, Enkin M, Lumley J. Social and professional support during childbirth. In: Chalmers I, Enkin M, Keirse MJNC, eds. Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, 1989:805-814.
38
In the Literature Commentary on: Continuous emotional support during labor in a US hospital. A randomized controlled trial. Kennell J, Klaus M, McGrath S, Robertson S, Hinkley C: JAMA 1991;265:2197-2201.
Labor Support: Many Unanswered Questions Remain These authors provide additional evidence that emotional support during labor has a beneficial effect on the outcome of birth. This phenomenon was recognized more than 40 years ago by Grantly DickRead in his classic monograph, Childbirth Without Fear. One of the most gratifying features of a normal labor is the personal interest and undivided attention given by the attendant of the parturient woman. This applies particularly to primiparae. However great the confidence and courage, the knowledge that someone competent to understand is nearby affords a comforting sense of security. (1)
In the latter half of the twentieth century the hospital has replaced the home as the birthing place, a transition that occurred out of concern for the occasional catastrophic complications of pregnancy and delivery. When this happened, however, the emotional support provided by women of the family and community and by midwife attendants that was characteristic of home births was often left behind. In addition, today in the hospital the laboring woman is often subjected to technologic and operative interventions, and birth attendants are nurses, nurse-midwives, and physicians whose focus is often on collecting and interpreting data rather than caring for the emotional needs of the woman in labor. The importance of the birth attendant was identified in one of the first randomized, controlled trials comparing continuous electronic fetal heart rate monitoring to intermittent fetal heart rate auscultation (2,3). Although perinatal outcome showed no difference in the various monitoring groups, women who underwent monitoring had a lower cesarean delivery rate, and fewer showed continuous fetal heart rate tracings characteristic of uteroplacental
insufficiency. The authors suggested that the decreased frequency of “fetal distress” associated with monitoring may have been related to the presence of a nurse at the woman’s bedside throughout her labor. The “active management of labor,” as described and practiced at the National Maternity Hospital in Dublin, is characterized by a high frequency of oxytocin augmentation of labor, a remarkably low cesarean delivery rate, minimal use of analgesia and epidural anesthesia, and perinatal outcomes comparable to those in hospitals with a less aggressive approach (4). Although it is difficult to know precisely which of the ingredients of this protocol is responsible for its success, the authors give much of the credit to the midwives who are in constant attendance with the women. The findings of Kennell et a1 in this United States study and their previous studies in Central America (5,6) strongly suggest that the emotional support of a nonfamily member reduces labor complications and the associated obstetric and surgical interventions. A recent randomized, controlled trial in a low-income population reported that supportive companionship provided by nonhealth care community volunteers decreased perceived pain and anxiety during labor and increased successful breastfeeding, although it did not influence the duration of labor (7). The preceding studies demonstrating the beneficial effects of a birth attendant (doula) were conducted in low socioeconomic populations. It is not clear that the same benefits would be found in women of high socioeconomic status. Hodnett and Osborn performed a randomized, prospective trial to assess the effect of a birth attendant on low-risk, middle-class women in Toronto (8,9). Although
BIRTH 19:l March 1992
women accompanied by a birth attendant used less pain medication and had fewer episiotomies, the study did not demonstrate an effect on length of labor, cesarean delivery rate, or use of interventions such as forceps and oxytocin augmentation of labor. Many questions remain unanswered about the effect of social and emotional support for women in labor. A thorough review of the existing trials and research emphasizes the paucity of good research on the subject (10). Further data are needed about the effect of birth attendants on populations of different socioeconomic status and cultural background. It is also important to assess whether obstetric nurses or midwives, on a one-to-one basis, can provide emotional support during labor equivalent to that of a birth attendant. If it becomes clear that women with designated birth attendants have better liibor and birth outcomes, we have to determine the criteria for selecting these attendants. Must they be nonfamily? Must they be women? Must they have had a normal birth experience? Will they add to the ever-increasing costs of maternity care? For seven years in the 1960s as a medical student, resident, and consultant at two homes for unwed mothers in Denver, I experienced at firsthand the importance of emotional and social support in pregnancy and childbirth. Both homes had freestanding birth centers, with obstetric coverage and consultiition provided by the University of Colorado Medical Center. I recall vividly that labors were seldom prolonged, women required little analgesia, the cesarean delivery rate was remarkably low, and the perinatal mortality was as low as anywhere else in the state. One might have expected otherwise, since patients were mostly young primigravidas whose lives were in turmoil. In addition to their support from other residents and social workers during the late weeks of pregnancy, they were attended in labor by middle-aged nurses who knew each woman personally and provided the continuity and emotional support that are characteristic of the modern monitrice or birthing assistant. Whatever else the studies on emotional support in labor have demonstrated, none has shown any adverse effects and most have shown an improvement in patient self-esteem and personal satisfac-
39 tion. For this reason alone, every maternity service should ensure the presence of a caring individual who has the time and motivation to be with women throughout labor. The challenge for modern obstetric care is to combine the benefits of properly applied technology with those that the presence of a birth attendant provides. Furthermore, and perhaps most difficult, this must be achieved in a way that does not incessantly escalate the cost out of proportion to the benefits. This study by Kennell et a1 demonstrates clearly the benefits to be gained from such practice. Its importance cannot be overemphasized. Watson A. Bowes Jr., M.D. Department of Obstetrics and Gynecology University of North Carolina Chapel Hill, NC References I . Dick-Read G. Childbirth Without Fear. New York: Harper & Brothers, 1944:150. 2. Haverkamp AD, Thompson HE, McFee JG, Cetrulo C. The evaluation of continuous fetal heart rate monitoring in high-risk pregnancy. Am J Obstet Gynecol 1976;125:310320. 3. Haverkamp AD, Orleans M, Langendoerfer S, et al. A controlled trial of the differential effects of intrapartum fetal monitoring. Am J Obstef Gynecol 1979;134:399408. 4. Boylan PC. Active management of labor: Results in Dublin, Houston, London, New Brunswick, Singapore, and Valparaiso. Birth 1989;16(3):114-118. 5 . Sosa R, Kennell J, Klaus M, et al. The effects of a supportive companion on perinatal problems, length of labor, and mother-infant interaction. N Engl J Med 1980;303:597-600. 6. Klaus M, Kennell J, Robertson S, Sosa R. Effects of social support during parturition on maternal-infant morbidity. Br Med J 1986;293:585-587. 7. Hofmeyr GJ, Nikodem VC, Wolman W, et al. Companionship to modify the clinical birth environment: Effects on progress and perceptions of labour, and breastfeeding. Br J Obstet Gynaecol 1991;98:75&764. 8. Hodnett ED, Osborn RW. Effects of continuous intrapartum professional support on childbirth outcomes. Res Nurs Health 1989;12:289-297. 9. Hodnett ED, Osborn RW. A randomized trial of the effects of monitrice support during labor: Mothers’ views two to four weeks postpartum. Birth 1989;16(4):177-183. 10. Keirse MJNC, Enkin M, Lumley J. Social and professional support during childbirth. In: Chalmers I, Enkin M, Keirse MJNC, eds. Effective Care in Pregnancy and Childbirth. Oxford: Oxford University Press, 1989:805-814.
