Science & Sensibility welcomes new contributor, Jackie Levine, as she shares with us her thoughts and compilation of the latest industry research about doula care.

Why is Labor Support So Important?

Ordinary intuition informs us, without reference to any study, that human touch and supportive contact, caring and calming behavior, and the sharing of the profound experience of birth with a loved one or close friend can all have powerful and positive effects on a woman in labor.

It turns out, our intuition is correct about the salutary effects of labor support; there is a bulging library of good research that clearly measures and identifies the benefits to mother and baby.

One comprehensive study published in Clinical Obstetrics and Gynecology (Kayne, Greulich, Albers, 2001) presents a thorough history of the doula and of continuous labor support in the US. The study highlights the social and medical rationales for doula care, including a meta-analysis of the research on labor support. This observation in the study rings particularly true: 'Perhaps the greatest lesson to be learned from these studies is that the laboring woman, not hospital policy, should decide who should be present for labor support'. That thinking harmonizes nicely with the statement of 'The Rights of Childbearing Women,' enumerated by Childbirth Connection and quoted in The Official Lamaze Guide: '#15- Every woman has the right to receive continuous social, emotional and physical support during labor and birth from a caregiver trained in labor support'.

Maternity care policies vary from institution to institution and from caregiver to caregiver. This is old news. In spite of considerable resources spent and the good intent of those caregivers, we know that some models of maternity care involve the overuse of harmful or ineffective but expensive protocols, and the underuse of ones that confer benefit; current care practices do not always reflect the host of systematic reviews that support best-evidence protocols. The Milbank report, as posted on Childbirth Connection, tells us that, in an analysis of practice bulletins issued by ACOG between 1998 and 2004, only 23% of those practice recommendations were based on Level A evidence (consistent science), 35% were assessed as Level B (inconsistent or limited evidence) and 42% were Level C (based on consensus or the opinions of experts). (Sakala C, Corry M, 2008.) Those numbers are reflected in the dismal ratings that the WHO gives the US: we are 49th in maternal mortality and 29th in infant mortality of 141 developed countries (WHO 2006). Clearly, we're not doing everything right and we all hope to see the day when evidence-based maternity care becomes the standard, replacing the existing welter of practices. But continuous labor support is Level A.

In the recent past, through the 1960s, when 'twilight sleep' for hospital birth was the paradigm, women did labor alone, and would awake from their anesthetized slumber the next day, perhaps, and ask 'Did I have a boy or a girl?' There are some women, of course who just don't want any 'company,' who find the intermittent visits from staff and caregivers to be enough interruption of concentration and purpose. These women typically invite their partner or other family members back into the room just for pushing and birth. I have known a very few who labor this way. But for most women, whether first-time mothers or not, continuous support and 'company' is a must. The arsenal of data showing improved obstetric outcomes with continuous labor support gives potent ammunition to every mother desiring it. I believe that at this juncture, very few caregivers will deny labor support to the mother. But that is not enough. The most effective labor support for mother and family is shown to be provided by the 'paraprofessional the doula '(Lantz,Low,Varkey, Watson, 2005).

Paying a doula fee is out of the reach of many, but several recent developments will make doula care increasingly accessible. Hospital-based programs that supply doulas to laboring women are few and far-between, but some insurance companies will now reimburse part of a doula's fee. And it's heartening, that the need for 'paraprofessional' labor support is now understood by those in government to be a vital part of good maternity care, evidenced by President Obama having signed an Omnibus bill in December which included 1.5 million dollars that The Health Resources and Services Administration (HRSA) will distribute to support community-based doula training programs on a grant basis. The Kayne study asserts that even in active management of labor 'continuous professional support is considered the most effective in reducing operative deliveries' (Kayne, Greulich, Albers, 2001). The rationale for doula care for all is further bolstered by the latest (2011) review from the Cochrane Database: Continuous Support for Women during Childbirth (Hodnett, Greulich, Albers, 2011). There is no question that doula support results in healthier mothers and babies, and safer labors and births.

How can we, educators, doulas, friends and family of birthing women, encourage, convince and facilitate this Healthy Birth Practice? In 2005, the Journal of Perinatal Education published a study on community-based doulas, advising childbirth educators in sum to act as advocates, and 'catalysts in their community to initiate highly personal support services' (Breedlove, 2005). In June 2010, Melinda Gates, of the Gates Foundation spoke at a Women Deliver Conference. Gates discussed a world where 'women are given the knowledge to make better decisions about their health and their children's health.' We can give birthing women the facts about support in labor, teach that our bodies are marvels and perfect for the job of birth, and that best evidence-care proves that to be so. The studies that refute interference with normal birth are mounting, and more and more the OB profession realizes, sometimes in a very self-congratulatory way, that things can and must change. (As example, see Changes in Episiotomy Practice: Evidence-based Medicine in Action, Lapin & Gossett, 2010.)

We know that continuous labor support does make for better outcomes, although research-wise, the exact reason that happens is not established. The Kayne study mentioned above says this: 'Whether it is the role of the support person as comforter or protector that leads to better obstetric outcomes is still unanswered.' The most recent Cochrane review theorizes that the stresses of hospital birth are dis-empowering, raising stress levels that impede both the dynamic and subtle mechanisms of normal labor. Research aside, we understand intuitively that continuous support in labor both protects and comforts; it acknowledges the vulnerability of a woman in labor and can provide, both through advocacy and unconditional acceptance of everything she does, an antidote to fear, and the path to a safe birth that will be remembered with joy.

References

1-Breedlove, G., Perceptions of Social Support from Pregnant and Parenting Teens Using Community-Based Doulas, J. Perinatal Educ 2005 Summer; 14(3): 15-22

2-Gates, Melinda. Full speech available at: http:/www.livestream.com/womendeliver/video?clipId=pla_7e848eb5-43eb-41e4-a5d3-e6de7cab31bc&utm­_source=1slibrary&utm_medium=ui-thumb.

3- Hodnett, E.D., Gales, S., Hofmeyr, G.J., Sakala, C., Weston, J. 2011, Continuous Support for Women during Childbirth, Cochrane Review

4-Kayne, M.A., Greulich, M.B., Albers, L. Doulas: An Alternative Yet Complementary Addition to Care During Childbirth, 2001, Clinical Obstetrics and Gynecology, 2001; .44(4):692-703

5-Doulas as Childbirth Paraprofessionals: Results from a National Survey, Lantz, P.M., Low L. K., Varkey, S., Watson R.L. Women's Health Issues, 2005,15:109-116.

6-Lappen, J.R., Gossett, D.R., Changes in Episiotomy Practice: Evidence-based Medicine in Action, Expert Rev of Obstet Gynecol. 2010;5(3):301-309

7- Lothian, Devries: The Official Lamaze Guide (New York: Meadowbrook Press, Simon & Schuster Publising, 2005, 2010), Appendix C, p 261.

8- Sakala, C., Corry, M. 2008, Evidence-based Maternity Care: What it is and What it Can Achieve. (Milbank Report

Posted by: Jackie Levine, LCCE,FACCE,CD, CLC

Published: February 21, 2011

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