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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 Selection criteria: All published and unpublished randomised controlled trials, cluster-randomised trials comparing continuous support during labour with usual care.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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... This has changed throughout the twentieth century, as the institutionalization of birth has led to big changes in birth care. Currently, in hospitals worldwide, the workload and institutional protocols make one-to-one intra-partum care difficult, and continuous support during labor has often become the exception rather than the norm (Bergström 2011;Hodnett et al. 2013;Bohren et al. 2017). the campaign, are examples of this. ...
... This has changed throughout the twentieth century, as the institutionalization of birth has led to big changes in birth care. Currently, in hospitals worldwide, the workload and institutional protocols make one-to-one intra-partum care difficult, and continuous support during labor has often become the exception rather than the norm (Bergström 2011;Hodnett et al. 2013;Bohren et al. 2017). Thus, continuous support during labor and childbirth has become a banner of birth activism, as scientific evidence demonstrates its benefits for women and babies, making clear the weaknesses of the dominant health care models in our society. ...
... Support in labor may reduce anxiety and stress, which has a negative effect on the childbirth experience and on the course of labor (Bergström 2011). Other reported benefits include positive feelings about the childbirth experience; increased spontaneous vaginal birth; shorter duration of labor; decreased caesarean birth, instrumental vaginal birth and use of any analgesia and low five-minute Apgar score (Bohren et al. 2017). In this sense, as in the 2015 IWRC campaign, childbirth organizations are committed to disseminating scientific evidence reiterating that all women should have support throughout labor and birth, in order to improve maternity care assistance, women's satisfaction about birth experiences and health outcomes. ...
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(1) Background: “To change the world, we must first change the way the babies are being born”, said Michel Odent, the famous French obstetrician and pioneer of the “natural birth” movement. This quotable phrase has been widespread in activism campaigns, and it refers to a project for social change that goes beyond birth. Conceiving childbirth in the broader social context, it is not surprising that this emblematic quote inspires emancipatory struggles around birth. This paper results from a study of childbirth activism in different European contexts, where the author explores the emergence and modes of action of social movements advocating for the humanization of childbirth and women’s rights in pregnancy and childbirth. (2) Methods: Starting from the analysis of the main characteristics of childbirth activism, in this paper the author briefly analyzes the cases of organizations from Portugal, Spain and the Netherlands, as well as a campaign promoted by the European Network of Childbirth Associations (ENCA). The author mobilizes empirical data resulting from a triangulation approach, essentially based on documentary analysis, complemented by conversations and participant observation in different settings. (3) Results: Preliminary results show how childbirth activism is contributing to the construction of alternative conceptions of birth, challenging established paradigms. (4) Conclusion: In its differences and similarities, childbirth activism assumes distinct features, but it also has the ability to adapt and promote changes, depending on the specificities of the contexts where it operates.
... To reduce the rate of CS, continuous support during labour has been valued and leads to fewer negative birth experiences as well. 35 Watchful attendance by midwives comprises continuous support, clinical assessment and responsiveness to women's needs. 36 The term expresses a combination of continuous support, clinical assessment and responsiveness. ...
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Objectives In this descriptive study, we aimed to assess how the index mode of birth and subsequent birth modes vary over time for public and private hospital maternity care funding models. The second aim was to determine to what extent the index mode of birth predicts subsequent birth modes in general and whether this differs in public versus private hospital maternity care funding models. With our aim, we have an innovative approach, specifically the women’s life course approach, which is hypothesis-generating and can be assessed in future studies. Design, setting and participants New South Wales population-linked data of low-risk women were analysed (2001–2016). Demographics and public/private care were recorded. Modes of the index birth and subsequent modes of second and third births (ie, spontaneous vaginal, instrumental vaginal elective/emergency caesarean birth) were registered. For those with 2 births and 3 births, 16 and 64 subsequent births patterns were created. Primary and secondary outcome measures Trend of index modes of birth and subsequent modes of birth over time and the prediction of subsequent birth modes based on the index birth. These outcomes were stratified for the initial maternity care funding model. Results In total, 172 041 low-risk nulliparous women were included in the initial cohort, 54.1% had a spontaneous index vaginal birth and 71% had their index birth in public hospitals. During the study period, 131 675 women had 2 births and 44 677 of these women had 3 births, respectively. Among women birthing in public hospitals, higher proportions of index and subsequent vaginal births were observed than in private hospitals, with fewer instrumental vaginal births and caesarean sections. Large differences were observed for birth patterns: vaginal-vaginal (public 55.8% vs private 36.8%) and vaginal-vaginal-vaginal (public 57.2% vs private 38.8%). Women with an index spontaneous vaginal birth showed a high probability (91.3%) of subsequent spontaneous vaginal births. When stratified by maternity care funding model, the probabilities were similar: 91.6% in public hospitals and 90.2% in private hospitals. Conclusions Our study of low-risk Australian women (2001–2011) found that those giving birth in public hospitals had higher proportions of spontaneous vaginal births compared with private hospitals, where caesarean sections were more common. Women with an index spontaneous vaginal birth had a very high probability to have subsequent vaginal births. These findings suggest that index mode of birth may be a predictor for subsequent modes of birth.
... There is sufficient scientific evidence that continuous support to mothers during childbirth by a companion of their choice can improve their birthing experience and birth outcomes. 1 A birth companion not only supports and counsels the mother during childbirth but also helps maintain transparency of treatment and continuous involvement of the family in the management of the mother. Allowing a birth companion is WHAT IS ALREADY KNOWN ON THIS TOPIC ⇒ The presence of a birth companion with the birthing mother has a positive impact on the maternal birthing experience and maternal and fetal outcomes and reduces the requirement for medical and surgical interventions. ...
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Background Allowing a birth companion is the basic right of a mother and is identified as an important component of respectful maternity care. The implementation of this intervention has been a challenge in heavy-load public health facilities in India. Local problem Despite the proven benefits of the presence of birth companions on maternal–fetal outcomes, there was no policy of allowing birth companions in our hospital. Methods and interventions We aimed to introduce and establish the practice of allowing birth companions for all eligible mothers admitted to the labour ward from 0% to 70% in 8 weeks duration. The study was conducted in the Department of Obstetrics and Gynecology, Lady Hardinge Medical College and Smt. Sucheta Kriplani Hospital, New Delhi. A quality improvement (QI) team was formed. After collecting the baseline data and observing the process flow, fishbone analysis was done to identify the main problems. Various change ideas were listed and tested in the form of plan-do-study-act (PDSA) cycles and ideas were either adapted or adopted. Simple interventions such as antenatal sensitisation and counselling of the mother and the family, WhatsApp groups, and monthly labour room induction classes for residents helped achieve the target. During COVID-19 pandemic, the practice of allowing birth companions was suspended temporarily but was rolled out again after the second wave of COVID-19 in COVID-19-negative and COVID-19 suspect labour wards. Results The median value of the percentage of mothers accompanied by birth companions marginally increased to 20% after the first PDSA cycle. Finally, after multiple PDSA cycles, we could achieve our goal in 8 weeks. During a pandemic, the project was suspended temporarily during the first two waves but was revived again and we succeeded in reaching the desired goal and sustaining the policy after fewer PDSA cycles compared with the first phase. Conclusion The application of QI methodology and teamwork is pivotal in implementing any novel idea for patient care without additional infrastructure, manpower or financial resources.
... Low-certainty evidence in the literature suggests that upright positions and continuous support during labor yield improvements in neonatal outcomes. 2,31 It was expected that physical therapy assistance during labor would positively influence these neonatal outcomes, given that the physical therapy interventions investigated in the studies included in the meta-analysis are meant to facilitate the acquisition of vertical positioning by the parturients. However, this result was not found in this review, likely attributable to the limited number of studies assessing these outcomes. ...
... Effective communication between patients and clinicians contributes to reducing high cesarean section rates [66]. Evidence from a Cochrane review suggests that continuous support during labor-one-to-one intrapartum support compared with usual care-is associated with a lower rate of cesarean sections, emphasizing the potential impact of staffing levels on provider-patient communication [67]. Therefore, from this perspective, higher staffing levels in the department should theoretically result in a lower ratio of cesarean sections. ...
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Introduction Cesarean deliveries account for approximately one-third of all births in Germany, prompting ongoing discussions on cesarean section rates and their connection to medical staffing and birth volume. In Germany, the majority of departments integrate obstetric and gynecological care within a single department. Methods The analysis utilized quality reports from German hospitals spanning 2015 to 2019. The outcome variable was the annual risk-adjusted cesarean section ratio—a metric comparing expected to observed cesarean sections. Explanatory variables included annual counts of physicians, midwives, and births. To account for case number-related staffing variations, full-time equivalent midwife and physician staff positions were normalized by the number of deliveries. Uni- and multivariate panel models were applied, complemented by multiple instrument variable analyses, including two-stage least square and generalized method of moments models. Results Incorporating data from 509 integrated obstetric departments and 2089 observations, representing 2,335,839 deliveries with 720,795 cesarean sections (over 60% of all inpatient births in Germany), multivariate model with fixed effects revealed a statistically significant positive association between the number of physicians per birth and the risk-adjusted cesarean section ratio (0.004, p = 0.004). Two-stage least square instrument variable analysis (0.020, p < 0.001) and a system GMM estimator models (0.004, p < 0.001) validated these results, providing compelling evidence for a causal relationship. Conclusion The study established a robust connection between the number of physicians per birth and the risk-adjusted cesarean section ratio in integrated obstetric and gynecological departments in Germany. While the cause of the effect remains unclear, one possible explanation is a lack of specialization within these departments due to the combined provision of both obstetric and gynecological care.
Article
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This is a protocol for a Cochrane Review (Qualitative). The objectives are as follows: The overall objective of the review is to describe and explore the perceptions and experiences of women, partners, community members, healthcare providers and administrators, and other key stakeholders who have experience with a labour companion. The review has the following objectives. To identify, appraise and synthesise qualitative research evidence on women’s, partners’, community members’, healthcare providers’ and administrators’, and other key stakeholders’ perceptions and experiences regarding labour companionship in health facilities. To identify barriers and facilitators to successful implementation and sustainability of labour companionship. To explore how the findings of this review can enhance our understanding of the related intervention review (Hodnett 2013).
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Background: Supportive care during labor, the primary role of intrapartum nurses and midwives, provides comfort to prepartum women and helps facilitate a positive labor experience. It has been argued that supportive care during labor reduces fear and anxiety as well as the resultant side effects. However, evidence supporting this argument is insufficient. Purpose: The aim of this study was to assess the effects of intrapartum supportive care on fear of delivery and on the key parameters of the labor process. Methods: This study used a single-blind randomized controlled trial approach. Randomized block assignment was used to assign 72 participants to either the intervention group (n = 36) or the control group (n = 36). Three women in the intervention group and six in the control group were later excluded from the study because they received emergency cesarean delivery. The intervention group received continuous supportive care, and the control group received routine hospital care. Results: No significant differences were identified between the two groups at baseline. The intervention group reported less fear of delivery during the active and transient phases of labor, higher perceived support and control during delivery, lower pain scores during the transient phase of labor, and a shorter delivery period than the control group (p < .05). However, no significant difference in the use of oxytocin during delivery between the two groups was reported. Conclusions/implications for practice: The results of this evidence-based study suggest that continuous support during labor has clinically meaningful benefits for women and that all women should receive this support throughout their labor and delivery process.
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Objective: The purpose of this guideline is to provide guidance for the intrapartum management of spontaneous labour, whether normal or abnormal, in term, healthy women, and to provide guidance in the management of first and second stage dystocia to increase the likelihood of a vaginal birth and optimize birth outcomes. Evidence: Published literature was retrieved through searches of PubMed and the Cochrane Library in October 2011 using appropriate, controlled vocabulary (e.g., labour pain; labour, obstetric; dystocia) and key words (e.g., obstetric labor, perineal care, dysfunctional labor). When appropriate, results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Results were limited to the last 10 years. Searches were updated on a regular basis and incorporated in the guideline up to June 15, 2015. Values: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Summary statements: RECOMMENDATIONS.
Article
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.
Article
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.