Cochrane Review on Effects of Continuous Labor Support
A new systematic review of the effects of continuous labor support was published in Issue 3, 2003 of The Cochrane Library. As Childbirth Connection is a partial supporter of this work, the review is available here, in full and without charge (click for a PDF). This page provides a brief overview.
Background to this systematic reviewThis new review is
descended from the first systematic review of controlled trial research
of effects of labor support, which appeared in Effective Care in Pregnancy and Childbirth
(1989). The current version replaces the Cochrane Review that Ellen
Hodnett kept up-to-date from 1995 through 2003: "Caregiver Support for
Women During Childbirth." That review contributed to the development of
policy statements and guidelines, legislation, and programs promoting
continuous labor support in various countries throughout the world.
new review adheres to established Cochrane Collaboration procedures for
limiting bias, including a thorough strategy for identifying relevant
studies, elimination of relevant studies that are not methodologically
adequate, and meta-analytic summary of remaining "included studies,"
when appropriate. The current version differs in several ways from the
one it replaces:
- new team: joining Dr. Hodnett, the lead reviewer, are
co-authors bringing perspectives on statistics/methodology (Simon
Gates), conditions in resource-constrained nations (Justus Hofmeyr),
and consumer concerns (Carol Sakala, Childbirth Connection's Director
- new title: "Continuous Support for Women During Childbirth"
- new protocol: the team began by developing a detailed formal
plan specifying the criteria and procedures they would follow to
prepare the new review
- new randomized controlled trials (RCTs): two new large RCTs
were incorporated; the new review summarizes experiences of nearly
13,000 women who participated in 15 trials that took place in 11
- expanded background and discussion sections: new topics
include explanations for effect of continuous labor support, growth of
availability and use of doulas or trained labor support companions, and
questions about effects of different types of providers of labor
- new subgroup analyses: the team included several new subgroup analyses comparing effects of continuous support under various conditions.
Research questionsThe main objective ("main
comparison") was to assess the effects, on mothers and their babies, of
continuous one-to-one support during labor compared with usual care, in
Subgroup analyses were planned to compare effects of continuous labor support with different
- policies about companions of the women's own choice: whether the study did or did not take place in a setting that allowed women to bring partners and other companions of choice
- policies about epidural analgesia: whether epidural was or was not routinely available
- policies about continuous electronic fetal monitoring (EFM): whether continuous EFM was or was not routine
- types of caregivers: whether the caregiver was a member of the hospital staff (e.g., nurse, midwife or student midwife) or someone from outside
- timing in the onset of continuous support: whether the support did or did not begin before active labor.
Outcomes of interestThe review identifies 30 outcomes of interest for the main comparison:
- labor events: e.g., artificial oxytocin, epidural analgesia
- birth events: e.g., cesarean birth, episiotomy
- newborn events: e.g., low 5-minute Apgar score, admission to special care nursery
- immediate maternal psychological outcomes: e.g., anxiety during labor, negative rating of experience
- longer-term maternal outcomes: e.g., postpartum depression, difficulty mothering.
outcomes for subgroup analyses were: analgesia/anesthesia, way of
giving birth (spontaneous, with vacuum extraction or forceps,
cesarean), low 5-minute Apgar scores, dissatisfaction or negative view
of childbirth experience, and postpartum depression.
Results of main comparisonNumerous graphs available within the full "Continuous Support..." review
(PDF) compare all data that were available from all included studies
for the specified outcomes of interest. Considering outcomes reported
in at least 4 studies involving at least 1,000 women, women who received continuous support were less likely than women who did not to:
Women receiving continuous support were more likely than those who did not to give birth spontaneously — with neither cesarean nor vacuum extraction nor forceps.
- have regional analgesia
- have any analgesia/anesthesia
- give birth with vacuum extraction or forceps
- give birth by cesarean
- report dissatisfaction or a negative rating of their experience.
Again, considering outcomes reported in 4 or more studies involving at least 1,000 women, continuous support was neither associated with shorter length of labor nor with decreased likelihood of:
- artificial oxytocin during labor
- low 5-minute Apgar scores
- newborn admission to special care nursery
- postpartum reports of severe labor pain.
Results of subgroup analysesData were not available to compare subgroups with respect to postpartum depression. Here are other subgroup analysis results:
- policies about companions of the women's own choice:
continuous support appeared to have a stronger impact on
analgesia/anesthesia use, spontaneous birth, and cesarean birth in
settings in which other support was not permitted; the subgroups were
not significantly different with respect to instrumental birth, low
5-minute Apgar scores, and dissatisfaction
- policies about epidural analgesia: continuous support
appeared to have a stronger impact on use of analgesia/anesthesia,
spontaneous birth, and cesarean birth when epidural analgesia was not
routinely available; the subgroups were not significantly different
with respect to instrumental birth, low 5-minute Apgar scores, and
- policies about continuous EFM: continuous support appeared
to have a stronger impact on spontaneous birth when EFM was not
routine; the subgroups were not significantly different with respect to
analgesia/anesthesia, instrumental birth, cesarean birth, low 5-minute
Apgar scores, and dissatisfaction
- type of caregiver: continuous support appeared to have a
stronger impact on anesthesia/analgesia, spontaneous birth, and
instrumental birth when the caregiver was not a hospital employee; it
only had an impact on cesarean birth when the caregiver was not a
hospital employee; the subgroups were not significantly different with
respect to dissatisfaction
- timing in the onset of continuous support: continuous
support appeared to have a stronger impact on analgesia/anesthesia,
spontaneous birth, and cesarean birth when it began before active
labor; the subgroups were not significantly different with respect to
instrumental birth and dissatisfaction.
Reviewers' conclusions: implications for practice, in part "Continuous
support during labour should be the norm, rather than the exception.
All women should be allowed and encouraged to have support people with
them continuously during labour. In general, continuous support from a
caregiver during labour appears to confer the greatest benefits when
the provider is not an employee of the institution, when epidural
analgesia is not routinely used, and when support begins in early
Reviewers' conclusions: implications for researchThe following settings warrant further research:
The following outcomes warrant further research:
- resource-constrained countries.
The following models warrant further research:
- effects on mothers' and babies' health and well-being in the postpartum period
- economic analysis of relative costs and benefits.
- North American doula model, with relationship established during
pregnancy, support during labor, and support in the postpartum period
- support by a female family member
- support by the husband/partner.
Citation for this reviewHodnett ED, Gates S, Hofmeyr G J, Sakala C. Continuous support for women during childbirth [PDF]. The Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.
About the Cochrane CollaborationTo learn more about the
Cochrane Collaboration, an international organization that prepares and
keeps up-to-date systematic reviews in many areas of health and
medicine, visit the Cochrane website.
Most recent page update: 7/30/2007
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