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Continuous support for women during childbirth

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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 Selection criteria: All published and unpublished randomised controlled trials, cluster-randomised trials comparing continuous support during labour with usual care.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. -- This review is published as a Cochrane Review in the Cochrane Database of Systematic Reviews 2017, Issue 7. Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and the Cochrane Database of Systematic Reviews should be consulted for the most recent version of the Review."
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... Support during childbirth has repeatedly been identified as the most pivotal factor for a positive childbirth experience 55,59,60 and can be offered by the childbearing woman's partner, friends, family members, and professionals. 61,62 Maternity care providers can provide support in their role, creating a "safe haven" for the birthing person. 5,58,63 Continuous support, or "being with" women 64 during labor and childbirth, has been found to increase the chance of spontaneous vaginal childbirth and positive childbirth experiences. ...
... 5,58,63 Continuous support, or "being with" women 64 during labor and childbirth, has been found to increase the chance of spontaneous vaginal childbirth and positive childbirth experiences. 25,61 Furthermore, Hildingsson et al 25 identified that birthing women who had a known midwife were more likely to have a positive experience of professional support during childbirth. This is congruent with research by O′ Brian et al, 65 which highlights the importance of trusting relationships with care providers for women's experience of feeling supported during childbirth. ...
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... Although the presence of companions was previously shown to be associated with favorable birth consequence (Bohren et al. 2017), this is the first study suggesting there may be a longer-term psychological benefit of having two lay birth companions in reducing childbirth trauma at 2 months postpartum. Although the effect sizes of the difference between groups were small, we suggest that any reduction in postpartum PTSD following a simple change such as allowing women to have more than one companion is an important clinical message. ...
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Background: Historically, women have been attended and supported by other women during labour. However, in hospitals worldwide, continuous support during labour has become the exception rather than the routine. Objectives: Primary: to assess the effects of continuous, one-to-one intrapartum support compared with usual care. Secondary: to determine whether the effects of continuous support are influenced by: (1) routine practices and policies; (2) the provider's relationship to the hospital and to the woman; and (3) timing of onset. Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013). Selection criteria: All published and unpublished randomised controlled trials comparing continuous support during labour with usual care. Data collection and analysis: We used standard methods of The Cochrane Collaboration Pregnancy and Childbirth Group. Two review authors independently evaluated methodological quality and extracted the data. We sought additional information from the trial authors. We used random-effects analyses for comparisons in which high heterogeneity was present, and we reported results using the average risk ratio (RR) for categorical data and mean difference (MD) for continuous data. Main results: Twenty-two trials involving 15,288 women met inclusion criteria and provided usable outcome data. Results are of random-effects analyses, unless otherwise noted. Women allocated to continuous support were more likely to have a spontaneous vaginal birth (RR 1.08, 95% confidence interval (CI) 1.04 to 1.12) and less likely to have intrapartum analgesia (RR 0.90, 95% CI 0.84 to 0.96) or to report dissatisfaction (RR 0.69, 95% CI 0.59 to 0.79). In addition, their labours were shorter (MD -0.58 hours, 95% CI -0.85 to -0.31), they were less likely to have a caesarean (RR 0.78, 95% CI 0.67 to 0.91) or instrumental vaginal birth (fixed-effect, RR 0.90, 95% CI 0.85 to 0.96), regional analgesia (RR 0.93, 95% CI 0.88 to 0.99), or a baby with a low five-minute Apgar score (fixed-effect, RR 0.69, 95% CI 0.50 to 0.95). There was no apparent impact on other intrapartum interventions, maternal or neonatal complications, or breastfeeding. Subgroup analyses suggested that continuous support was most effective when the provider was neither part of the hospital staff nor the woman's social network, and in settings in which epidural analgesia was not routinely available. No conclusions could be drawn about the timing of onset of continuous support. Authors' conclusions: Continuous support during labour has clinically meaningful benefits for women and infants and no known harm. All women should have support throughout labour and birth.
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Aim: To determine of continuous, effective and comfortable nursing care can lower the occurrence of negative psychology and reduce complications during the parturient period. Methods: 240 parturient women hospitalized at Department of Obstetrics and Gynecology, Affiliated Hospital, Zunyi Medical College from July 2004 to February 2005 were divided into two groups at random: 120 patients treated with comfortable nursing as observation group, providing comfortable environment, psychological communication for parturient with accompanying of family members. 120 patients in the control group received routine care to dispose the whole birth process. The numbers of the people who had the manifestation of anxiety, fear, adamancy, rivalry, depression and common etc. were compared between the two groups. The condition of active time in the first birth process was compared between the two groups. The effects of the two kinds of nursing cares on the birth process and parturition manner in the process of birth were compared. The quantity of bleeding was compared between the time of birth and the time after birth of the two groups. The incidence was compared between the anoxia of newborn in the two groups. Results: Totally 240 gravidas were involved in the result analysis without drop. 1 Comparison of the mental state in the parturient of the two groups: Common people were 87 cases and 21 cases, respectively. The number of anxiety, fear, adamancy, rivalry, depressive positive people, and there was significant difference of the general positive rate (21, 42; 2, 13; 7, 21; 0, 9; 3, 14; 27.50%,82.50%; χ2=73.3, P < 0.001). 2 Comparison of the birth process between the parturient in the two groups: The average value in active phase of the first stage of birth and the general process of birth in the observation group was lower than that in the control group [(145.6±34.9), (275.3±74.6) minutes; (436.6±128.7), (648.3±134.6) minutes; t=17.25, 12.45, P < 0.001]. 3 Comparison of the parturition manners, natural parturition and condition of birth difficulty of the parturient in the two groups: 109 cases were natural parturient by vagina, 8 cases were dissected the womb to birth and 3 cases were aided to birth by cephalotracter and suck the placenta in the observation group. Sixty-nine cases were natural parturient by vagina, 42 cases were dissected the womb to birth and 9 cases were aided to birth by cephalotracter and suck the placenta in the control group, and there were significant differences between the two groups (χ2=34.8, P < 0.001). 4 Comparison of the quantity of bleeding between the time of birth and the time after birth of the two groups: The average value in the observation group was significantly lower than that in the control group [(169±43.5), (192±31.6) mL;t=4.68, P < 0.001]. 5 Comparison of the Apgar score in the neonates of the two groups: The Apgar score was ≥ 8 points of the neonates in the observation group, which was higher than that in the control group (115, 97 cases, χ2=13.1, P < 0.001). Conclusion: Continuous, effective and comfortable nursing can keep parturients in a relaxing, pleasant, comfortable and confident state-of-mind, thus, it is beneficial to reduce the parturition complication.